Anthem Blue Cross (HMO, PPO, EPO)
Keytruda (Solr) (pembrolizumab)
Drugs for Cancer : Drugs for Cancer
  • Breast Cancer: Triple Negative, Cutaneous Squamous Cell Carcinoma (cSCC), Head and Neck Cancer, Hodgkin Lymphoma (HL), Malignant Pleural Mesothelioma, Metastatic Prostate Cancer, Uveal Melanoma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Cervical Cancer, Endometrial Cancer, Esophageal Cancer, Melanoma (MEL), NSCLC EGFR Mutated, NSCLC Systemic Therapy, Solid Tumor with deficient mismatch repair (dMMR):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Gastric Cancer:
    Duration: 1 year(s)

    Hepatocellular Carcinoma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Duration of Reauthorization: N/A
    Diagnosis Types: 6 of Advanced disease;as a single agent;Hepatocellular Cancer;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;not receiving therapy with a systemic immunosuppressant;patients who have received at least one prior therapy
    Child-Pugh Score Required for Treatment: 1 of Class A (5-6)

    Kidney Cancer:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: Payer Specific
    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 Inlyta;Lenvima

    Merkel Cell Carcinoma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of NCCN Guidelines
    Diagnosis Types: 4 of Advanced disease;as a single agent;Merkel Cell Carcinoma;metastatic;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Recurrent local/regional disease

    Tumor Mutational Burden-High (TMB-H) Cancer:
    Duration: 1 year(s)
    Documented Diagnosis: No
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    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: Payer Specific
    Diagnosis Types: 4 of as a single agent;disease progression during or following platinum-containing chemotherapy;In patients who are not eligible for any platinum-containing chemotherapy;Locally advanced or metastatic urothelial carcinoma;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Not eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1;Progression within 12 mos. of neoadjuvant or adjuvant treatment with platinum-containing regimen;subsequent therapy
    ECOG Score Requirement Included in Policy: <= 2
    Individual cannot have a diagnosis of any of the following: 1 of History of severe autoimmune disease;Other;Require systemic immunosuppression

  • Prior Authorization: Breast Cancer: Triple Negative, Cutaneous Squamous Cell Carcinoma (cSCC), Head and Neck Cancer, Hepatocellular Carcinoma, Hodgkin Lymphoma (HL), Kidney Cancer, Malignant Pleural Mesothelioma, Metastatic Prostate Cancer, Urothelial/Bladder Cancer, Uveal Melanoma:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

    Cervical Cancer, Endometrial Cancer, Esophageal Cancer, Melanoma (MEL), Merkel Cell Carcinoma, NSCLC EGFR Mutated, NSCLC Systemic Therapy, Solid Tumor with deficient mismatch repair (dMMR):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 1 year(s)

    Gastric Cancer:
    Duration: 1 year(s)

    Tumor Mutational Burden-High (TMB-H) Cancer:
    Medical Test Required: Yes
    Duration: 1 year(s)