- PA Applies
- Prior Authorization: Breast Cancer: HR+ (HER2-):
Duration: 1 year(s)
Breast Cancer: HR+ (HER2+), Endometrial Cancer, NSCLC Systemic Therapy, Ovarian Cancer, Pancreatic Cancer:
Documented Diagnosis: Yes
Duration: 1 year(s)
Breast Cancer: Triple Negative:
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;
- Breast Cancer: HR+ (HER2-):
Duration: 1 year(s)
Breast Cancer: HR+ (HER2+), Endometrial Cancer, NSCLC Systemic Therapy, Pancreatic Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Breast Cancer: Triple Negative:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Ovarian Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Concomitant Therapy Requirement: carboplatin
Diagnosis Types: 4 of as a single agent;epithelial ovarian, fallopian tube, or primary peritoneal cancer;in combination with a taxane hypersensitivity;Ovarian Cancer;persistent or recurrent disease
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