Anthem Blue Cross (HMO, PPO, EPO) |
Bavencio (avelumab) |
Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: Kidney Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Merkel Cell Carcinoma: Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 1 year(s)
Urothelial/Bladder Cancer: Documented Diagnosis: Yes
Duration: 1 year(s)
- Step Therapy: Urothelial/Bladder Cancer:
ST Single Generic
- Kidney Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
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: Inlyta
Merkel Cell Carcinoma: Age Requirement: >= 12
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 AHFS Guidelines;Clinical Pharmacology;FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 3 of Merkel Cell Carcinoma;metastatic;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy
Urothelial/Bladder 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 NCCN Guidelines;Payer Specific
Diagnosis Types: 3 of As monotherapy;disease progression after platinum based chemotherapy;Locally advanced or metastatic urothelial carcinoma;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Progression within 12 mos. of neoadjuvant or adjuvant treatment with platinum-containing regimen;Subsequent therapy after previous platinum treatment
ECOG Score Requirement Included in Policy: <= 2
Individual cannot have a diagnosis of any of the following: 1 of Active immune-mediated disease;Disease progression while on or following PD-1/PD-L1 therapy;Require systemic immunosuppression
- PA Applies
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;
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