- Prior Authorization: Cervical Cancer, Colorectal Cancer, Diabetic Retinopathy, Endometrial Cancer, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Malignant Pleural Mesothelioma, Neovascular (Wet) Age-Related Macular Degeneration (AMD), NSCLC Systemic Therapy, Ovarian Cancer, Recurrent Glioblastoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
Kidney Cancer: Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
- Available only through Specialty Pharmacy;
For FAX form click HERE Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites: Log in to Surescripts Log in to CoverMyMeds; For details on drug coverage click HERE; Dosing Limit: 1.25 mg per eye; each eye may be treated as frequently as every 4 weeks;
- Cervical Cancer, Diabetic Retinopathy, Endometrial Cancer, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Malignant Pleural Mesothelioma, Neovascular (Wet) Age-Related Macular Degeneration (AMD), NSCLC Systemic Therapy, Recurrent Glioblastoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Colorectal Cancer: Duration: 1 year(s)
Documented Diagnosis Requirement: Explicitly Documented
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
Kidney Cancer: 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;Payer Specific
Supporting Documentation Requirements: Histology
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 Afinitor (everolimus);Erlotinib;Interferon Alfa
Ovarian 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
Concomitant Therapy Requirement: 1 of Chemotherapy;Olaparib
Diagnosis Types: 4 of Adjuvant therapy;Advanced disease;as a single agent;As maintenance therapy as a single agent following recurrence therapy with chemotherapy plus bevacizumab;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance therapy;Maintenance therapy for stage II-IV disease if complete clinical remission or partial remission to primary therapy including bevacizumab as: a single agent or in combination with olaparib in patients BRCA1/2 wild-type or unknown;Metastatic disease;Recurrent disease;Refractory disease;Relapsed disease;Stage III or IV disease following initial surgical resection
- PA Applies
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