- 1;
- Quantity Limit: 21 tablets per 30 day(s).
- Quantity Limit: limit maximum 30 EA PER 13 day(s)
- Acute Myeloid Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
Supporting Documentation Requirements: FLT3 mutation as detected by an FDA-approved test
Quantity Limit: N/A
Use of Biomarkers in Policy: FLT3 mutation
Diagnosis Types: 2 of FLT3 mutation-positive AML detected by FDA-approved test;Post Remission Therapy;Relapsed/Refractory acute myeloid leukemia
Excludes Coverage in Maintenance Setting: No
Gastrointestinal Stromal Tumor:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Hepatocellular Carcinoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Unspecified
Duration of Reauthorization: N/A
Diagnosis Types: 2 of Advanced disease;Hepatocellular Cancer;Unresectable disease
ECOG Score Requirement Included in Policy: N/A
Kidney Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Unspecified
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
Soft Tissue Sarcoma:
Duration: 1 year(s)
Reauthorization Required: No
Medical Test Required: No
Specialty Pharmacy Provider(s): Unspecified
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
Diagnosis Types: Soft tissue sarcoma
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
Thyroid Carcinoma:
Duration: 1 year(s)
|