- Colorectal Cancer:
Age Requirement: >= 12
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis Requirement: Inferred from Available Documentation
Medical Test Required: No
Specialist Type(s): 1 of Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
Esophageal Cancer, Head and Neck Cancer, Hodgkin Lymphoma (HL), Malignant Pleural Mesothelioma, Melanoma (MEL), Uveal Melanoma:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Gastric Cancer:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Hepatocellular Carcinoma:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Duration of Reauthorization: = 12 month(s)
Diagnosis Types: 3 of For patients who received previous treatment with Lenvima;For patients who received previous treatment with Nexavar/sorafenib;has not received treatment with another PD-1 agent;Hepatocellular Cancer
ECOG Score Requirement Included in Policy: N/A
Child-Pugh Score Required for Treatment: Class A (5-6)
Kidney Cancer:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;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
Concomitant Use With: 1 of Cabometyx (cabozantinib);Yervoy
Merkel Cell Carcinoma:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
Diagnosis Types: 2 of Merkel Cell Carcinoma;metastatic
NSCLC EGFR Mutated, NSCLC Systemic Therapy:
Age Requirement: >= 18
Duration: 6 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)
Small Cell Lung Cancer:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
ECOG Score Requirement Included in Policy: N/A
Diagnosis Types: Small Cell Lung Cancer
Tumor Mutational Burden-High (TMB-H) Cancer:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: No
Medical Test Required: No
Specialist Type(s): Appropriate Specialist
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Urothelial/Bladder Cancer:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Drug Policy Based On: FDA Approved Indications
Diagnosis Types: 2 of Adjuvant treatment of urothelial carcinoma at high risk of recurrence after undergoing radical resection of UC;All FDA-approved indications;Urothelial carcinoma
ECOG Score Requirement Included in Policy: N/A
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