- Breast Cancer: HR+ (HER2-), Thyroid Carcinoma:
Duration: 1 year(s)
Hodgkin Lymphoma (HL), Neuroendocrine Tumor (NET), Tuberous Sclerosis Complex:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Kidney 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
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 Avastin;Lenvima
- PA Applies
- Step Therapy: Hodgkin Lymphoma (HL), Kidney Cancer:
ST Single Generic
Thyroid Carcinoma:
ST Generic and Brand
- Prior Authorization: Breast Cancer: HR+ (HER2-), Thyroid Carcinoma:
Duration: 1 year(s)
Hodgkin Lymphoma (HL), Kidney Cancer, Neuroendocrine Tumor (NET), Tuberous Sclerosis Complex:
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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