- PA Applies
- Colorectal Cancer:
Duration: 1 year(s)
Documented Diagnosis Requirement: Explicitly Documented
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
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
Duration of Reauthorization: N/A
Diagnosis Types: 2 of For patients who received previous treatment with Nexavar/sorafenib;Hepatocellular Cancer
ECOG Score Requirement Included in Policy: N/A
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: 3 of as a single agent;Gastrointestinal stromal tumor (GIST);Pleomorphic rhabdomyosarcoma;Rhabdomyosarcoma;Soft tissue sarcoma;Solitary fibrous tumor/hemangiopericytoma;Unresectable or metastatic
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
- Quantity Limit: 84 tablets per 28 day(s).
- Prior Authorization: Colorectal Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Gastrointestinal Stromal Tumor, Hepatocellular Carcinoma, Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location;
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;
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