- Quantity Limit: limit maximum 300 ML PER 25 day(s)
- Quantity Limit: 30 day supply per 1 fill(s).
- Prior Authorization: Multiple Sclerosis (MS):
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Secondary Progressive Multiple Sclerosis:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Breast Cancer: HR+ (HER2-), Thyroid Carcinoma:
Duration: 1 year(s)
Hodgkin Lymphoma (HL), Neuroendocrine Tumor (NET), Tuberous Sclerosis Complex:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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: 1 of NCCN Guidelines;Payer Specific
ECOG Score Requirement Included in Policy: N/A
Policy Includes Reference to Coverage for Non Clear Cell Histology: Yes
If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
Concomitant Use With: 1 of Avastin;Lenvima
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