Cigna + Oscar
Iclusig (ponatinib)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Endometriosis:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Metastatic Prostate Cancer, Non-Metastatic Prostate Cancer, Uterine Fibroids:
    Documented Diagnosis: Yes

  • Breast Cancer: gBRCA:
    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

  • Oral anti-cancer drug.
  • Step Therapy: PID: Immune Globulin:
    ST Single Brand