- Orally administered anticancer medication.
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
- Prior Authorization: Metastatic Prostate Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Ovarian Cancer:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: Ovarian Cancer:
ST Single Brand
- Metastatic Prostate Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Ovarian Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: Payer Specific
Diagnosis Types: 2 of epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance treatment after a complete or partial response to platinum-based chemotherapy;positive BRCA mutation based on an FDA approved test;Treated with at least 2 prior lines chemotherapy
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