- Quantity Limits Apply
- Hepatocellular Carcinoma:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Duration of Reauthorization: = 1 plan year
Diagnosis Types: 3 of All FDA-approved indications;for adults who received previous treatment with sorafenib;Hepatocellular Cancer;NCCN recommended level 2a-b or better
ECOG Score Requirement Included in Policy: N/A
Child-Pugh Score Required for Treatment: Class A (5-6)
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: FDA Approved Indications
Supporting Documentation Requirements: 2 of Chart Notes;Lab Tests;Medication History
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 CYP3A4 inducer;Opdivo
Thyroid Carcinoma:
Age Requirement: >= 12
Duration: 12 Month(s)
Specialist Required: Yes
- Step Therapy: Thyroid Carcinoma:
ST Single Brand
- Prior Authorization: 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: >= 12
Duration: 12 Month(s)
- Anti-Cancer:Maximum $200 copayment per State Law.
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