Acute Myeloid Leukemia:
Age Requirement: < 19
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
Quantity Limit: N/A
Criteria for Reauthorization: No evidence of disease progression or unacceptable toxicity
Use of Biomarkers in Policy: FLT3 mutation
Diagnosis Types: 2 of FLT3 mutation-positive AML detected by FDA-approved test;Medically accepted uses supported by NCCN Category 1, 2A or 2B level of evidence;Relapsed/Refractory acute myeloid leukemia
Excludes Coverage in Maintenance Setting: No

Gastrointestinal Stromal Tumor:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): BriovaRx
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)

Hepatocellular Carcinoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Duration of Reauthorization: = 12 month(s)
Diagnosis Types: 2 of extensive tumor burden;Hepatocellular Cancer;individual is not a candidate for surgery;metastatic disease;Metastatic disease;not a transplant candidate and disease is unresectable
ECOG Score Requirement Included in Policy: N/A

Kidney Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
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

Soft Tissue Sarcoma:
Duration: 12 Month(s)
Reauthorization Required: Yes
Medical Test Required: No
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
Diagnosis Types: 1 of All medically accepted indications;Angiosarcoma;Gastrointestinal stromal tumor (GIST);Solitary fibrous tumor/hemangiopericytoma
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes

Thyroid Carcinoma:
Duration: 12 Month(s)