- Step Therapy Applies
- Quantity Limits Apply
- Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
- Breast Cancer: HR+ (HER2-):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Hodgkin Lymphoma (HL):
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
Kidney 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: = 1 plan year
Drug Policy Based On: FDA Approved Indications
Supporting Documentation Requirements: 2 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
Neuroendocrine Tumor (NET):
Age Requirement: >= 18
Duration: 6 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)
Tuberous Sclerosis Complex:
Age Requirement: >= 18
Duration: 1 plan year
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
- Prior Authorization: Breast Cancer: HR+ (HER2-):
Age Requirement: >= 18
Duration: 6 Month(s)
Hodgkin Lymphoma (HL):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Kidney Cancer:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Neuroendocrine Tumor (NET):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Tuberous Sclerosis Complex:
Age Requirement: >= 18
Duration: 1 plan year
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