- 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: Esophageal Cancer, Head and Neck Cancer, Hepatocellular Carcinoma, Hodgkin Lymphoma (HL), Kidney Cancer, Malignant Pleural Mesothelioma, Merkel Cell Carcinoma, Urothelial/Bladder Cancer, Uveal Melanoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
Gastric Cancer:
Duration: 1 year(s)
Melanoma (MEL), NSCLC EGFR Mutated, NSCLC Systemic Therapy:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
- PA Applies
- Esophageal Cancer, Head and Neck Cancer, Hodgkin Lymphoma (HL), Malignant Pleural Mesothelioma, Uveal Melanoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Gastric Cancer:
Duration: 1 year(s)
Hepatocellular Carcinoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Duration of Reauthorization: N/A
Diagnosis Types: 4 of Advanced disease;as a single agent;has not received treatment with another PD-1 agent;Hepatocellular Cancer;subsequent therapy
ECOG Score Requirement Included in Policy: <= 2
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: Payer Specific
Supporting Documentation Requirements: Histology
ECOG Score Requirement Included in Policy: <= 2
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: 2 of Opdivo;Yervoy
Melanoma (MEL), NSCLC EGFR Mutated, NSCLC Systemic Therapy:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Merkel Cell Carcinoma:
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 AHFS Guidelines;Clinical Pharmacology;FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 4 of as a single agent;Merkel Cell Carcinoma;metastatic;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Recurrent local/regional disease
Urothelial/Bladder Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Diagnosis Types: 4 of as a single agent;disease progression during or following platinum-containing chemotherapy;Locally advanced or metastatic urothelial carcinoma;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Progression within 12 mos. of neoadjuvant or adjuvant treatment with platinum-containing regimen
ECOG Score Requirement Included in Policy: <= 2
Individual cannot have a diagnosis of any of the following: 1 of Disease progression while on or following PD-1/PD-L1 therapy;History of severe autoimmune disease;Other;Require systemic immunosuppression
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