- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- 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
- Prior Authorization: Hepatocellular Carcinoma, Kidney Cancer, Malignant Pleural Mesothelioma, NSCLC Systemic Therapy, Uveal Melanoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
Melanoma (MEL):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
- PA Applies
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