- Cluster Headache:
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Neurologist;Pain Management Specialist
Reauthorization Required: No
Duration of Reauthorization: N/A
- Ovarian Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of Clinical Pharmacology;NCCN Guidelines
Diagnosis Types: 2 of Advanced disease;Advanced ovarian, fallopian tube or primary peritoneal cancers after 3 or more prior chemo regimens with HRD+ mutations by deleterious or suspected deleterious BRCA mutation or genomic instability and progression >6 months after response to the last platinum-based therapy;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance treatment after a complete or partial response to platinum-based chemotherapy;Recurrent disease
Supporting Documentation Requirements: Homologous recombination deficiency (HRD) testing
- Step Therapy: Ankylosing Spondylitis (AS), Hidradenitis Suppurativa (HS), Uveitis:
ST Multiple Generics
Crohn's Disease (CD), Juvenile Idiopathic Arthritis, Psoriasis (PsO), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC): ST Single Generic
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