- Hepatocellular Carcinoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Duration of Reauthorization: N/A
Diagnosis Types: 5 of Advanced disease;has not received treatment with another PD-1 agent;Hepatocellular Cancer;not receiving therapy with a systemic immunosuppressant;subsequent therapy
ECOG Score Requirement Included in Policy: <= 2
Kidney Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Supporting Documentation Requirements: Histology
ECOG Score Requirement Included in Policy: <= 2
Policy Includes Reference to Coverage for Non Clear Cell Histology: No
If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
Concomitant Use With: Opdivo
Malignant Pleural Mesothelioma, NSCLC Systemic Therapy, Uveal Melanoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Melanoma (MEL):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
- Step Therapy: ST_APPLIES
- Prior Authorization: Multiple Sclerosis (MS):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- PA Applies
- Pulmonary Arterial Hypertension:
Duration: 1 year(s)
- Quantity Limit: 4 capsules per 1 day(s).
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