- 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
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