- Step Therapy Applies
- Kidney Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
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
- Prior Authorization: Kidney Cancer:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Thyroid Carcinoma:
Thyroid Carcinoma
1. Initial Authorization
a. Inlyta will be approved based on all of the following criteria:
(1) One of the following diagnosis:
(a) Follicular Carcinoma
(b) Hurthle Cell Carcinoma
(c) Papillary Carcinoma
-AND-
(2) One of the following:
(a) Unresectable recurrent
(b) Persistent locoregional disease
(c) Metastatic disease
-AND-
(3) Disease is refractory to radioactive iodine treatment
Authorization will be issued for 12 months.
2. Reauthorization
a. Inlyta will be approved based on the following criterion:
(1) Patient does not show evidence of progressive disease while on Inlyta therapy
Authorization will be issued for 12 months.
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
- Orally administered anticancer medication.
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