- 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)
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