- Quantity Limits Apply
- Anti-Cancer:Maximum $200 copayment per State Law.
- Endometrial Cancer:
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: = 12 month(s)
Hepatocellular Carcinoma:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist
Duration of Reauthorization: Unspecified
Diagnosis Types: 2 of All FDA-approved indications;Hepatocellular Cancer;NCCN recommended level 2a-b or better
ECOG Score Requirement Included in Policy: N/A
Kidney Cancer:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
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:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
- Prior Authorization: Endometrial Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Hepatocellular Carcinoma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Kidney Cancer:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Thyroid Carcinoma:
Age Requirement: >= 18
Duration: 12 Month(s)
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