| HealthNet - All plan years |
| Xyntha (antihemophil FVIII,B-dom del) |
| Drugs for the Blood : Drugs to Prevent Bleeding |
- 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 GNRH criteria for drug coverage click HERE | For details on Infertility criteria for drug coverage click HERE;
- Multiple Sclerosis (MS):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
- Endometrial Cancer:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Hepatocellular Carcinoma:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist
Duration of Reauthorization: Unspecified
Diagnosis Types: 2 of All FDA-approved indications;Hepatocellular Cancer;NCCN recommended level 2a-b or better
ECOG Score Requirement Included in Policy: N/A
Kidney Cancer:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
ECOG Score Requirement Included in Policy: N/A
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: 1 of Afinitor (everolimus);Keytruda
Thyroid Carcinoma:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
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