- Quantity Limit: 200 needles per 30 day(s).
- Hepatocellular Carcinoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Duration of Reauthorization: = 12 month(s)
Diagnosis Types: 2 of Hepatocellular Cancer;Metastatic disease;Unresectable disease
ECOG Score Requirement Included in Policy: N/A
Kidney 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: NCCN Guidelines
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
Concomitant Use With: 1 of Afinitor (everolimus);Keytruda
Thyroid Carcinoma:
Duration: 12 Month(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;
- Prior Authorization: Neuroendocrine Tumor (NET):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
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