- Quantity Limits Apply
- Breast Cancer: gBRCA, Breast Cancer: Triple Negative:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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: 2 of All FDA-approved indications;deleterious or suspected deleterious germline and/or somatic BRCA mutation;Disease progression on three or more prior lines of chemotherapy;epithelial ovarian, fallopian tube, or primary peritoneal cancer;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: 3 of BRCA mutation as detected by an approved FDA laboratory test;Chart Notes;Lab Tests
Pancreatic Cancer:
Age Requirement: >= 18
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Anti-Cancer: Maximum $200 copayment per State Law.
- Prior Authorization: Breast Cancer: gBRCA, Breast Cancer: Triple Negative:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Ovarian Cancer:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Pancreatic Cancer:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
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