- Prior Authorization: Metastatic Castrate-Sensitive Prostate Cancer (mCSPC), Non-Metastatic Prostate Cancer:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Metastatic Prostate Cancer:
Documented Diagnosis: Yes
Age Requirement: < 19
Duration: 12 Month(s)
Reauthorization Required: Yes
- Orally administered anticancer medication.
- Metastatic Castrate-Sensitive Prostate Cancer (mCSPC):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist;Urologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Metastatic Prostate Cancer:
Age Requirement: < 19
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Non-Metastatic Prostate Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): 1 of Avella Specialty Pharmacy;BriovaRx
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
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