Health Net
Keytruda (Solr) (pembrolizumab)
Drugs for Cancer : Drugs for Cancer
  • 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