- Limited Access. Anti-Cancer: Maximum $200 copayment per State Law.
- Prior Authorization: Ovarian Cancer:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Ovarian Cancer:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 3 of Advanced ovarian, fallopian tube or primary peritoneal cancers after 3 or more prior chemo regimens with HRD+ mutations by deleterious or suspected deleterious BRCA mutation or genomic instability and progression >6 months after response to the last platinum-based therapy;All FDA-approved indications;maintenance treatment after a complete or partial response to platinum-based chemotherapy;Treated with at least 2 prior lines of platinum based chemotherapy
Supporting Documentation Requirements: 4 of BRCA mutation as detected by an approved FDA laboratory test;Chart Notes;Homologous recombination deficiency (HRD) testing;Lab Tests
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