- Step Therapy Applies
- Breast Cancer: Triple Negative, NSCLC EGFR Mutated, NSCLC Systemic Therapy:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Cervical Cancer: 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)
Colorectal Cancer: Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis Requirement: Explicitly Documented
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
Cutaneous Squamous Cell Carcinoma (cSCC), Head and Neck Cancer: 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: = 6 month(s)
Endometrial Cancer: Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
Esophageal Cancer, Malignant Pleural Mesothelioma: 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: >= 6 month(s)
Gastric Cancer: Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Hepatocellular Carcinoma: Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Duration of Reauthorization: = 6 month(s)
Diagnosis Types: 2 of All FDA-approved indications;as a single agent;For patients who received previous treatment with Nexavar/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)
Hodgkin Lymphoma (HL): Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Kidney Cancer: 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: = 6 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 1 of Chart Notes;Diagnosis of Disease;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
Concomitant Use With: 1 of Inlyta;Lenvima
Melanoma (MEL): Age Requirement: >= 12
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Merkel Cell Carcinoma: Age Requirement: >= 2
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: ACCC;AHFS Guidelines;Clinical Pharmacology;Elsevier/Gold Standard Clinical Pharmacology;FDA Approved Indications;Micromedex;NCCN Guidelines;United States Pharmacopeia (USP);Wolters Kluwer Lexi-Drugs
Diagnosis Types: 4 of Locally advanced disease;Merkel Cell Carcinoma;metastatic disease;Recurrent disease
Metastatic Prostate Cancer: Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Small Cell Lung Cancer: 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: = 6 month(s)
ECOG Score Requirement Included in Policy: N/A
Diagnosis Types: 3 of as a single agent;Relapsed or primary progressive disease as subsequent therapy;Small Cell Lung Cancer
Solid Tumor with deficient mismatch repair (dMMR): Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
Tumor Mutational Burden-High (TMB-H) Cancer: Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: No
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
Urothelial/Bladder 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: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 1 of disease progression during or following platinum-containing chemotherapy;In patients who are not eligible for any platinum-containing chemotherapy
ECOG Score Requirement Included in Policy: N/A
Uveal Melanoma: Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Appropriate Specialist
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
- Prior Authorization: Breast Cancer: Triple Negative, Endometrial Cancer, NSCLC EGFR Mutated, NSCLC Systemic Therapy:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Cervical Cancer, Cutaneous Squamous Cell Carcinoma (cSCC), Esophageal Cancer, Head and Neck Cancer, Kidney Cancer, Malignant Pleural Mesothelioma, Small Cell Lung Cancer: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Colorectal Cancer, Hodgkin Lymphoma (HL), Metastatic Prostate Cancer, Solid Tumor with deficient mismatch repair (dMMR): Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
Gastric Cancer: Age Requirement: >= 18
Duration: 6 Month(s)
Hepatocellular Carcinoma: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Melanoma (MEL): Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
Merkel Cell Carcinoma: Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 1 plan year
Reauthorization Required: Yes
Tumor Mutational Burden-High (TMB-H) Cancer: Medical Test Required: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
Urothelial/Bladder Cancer: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Uveal Melanoma: Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
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