Western Health Advantage
Ukoniq (umbralisib)
Drugs for Cancer : Drugs for Cancer
  • Cervical Cancer, Diabetic Retinopathy, Endometrial Cancer, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Malignant Pleural Mesothelioma, Neovascular (Wet) Age-Related Macular Degeneration (AMD), NSCLC Systemic Therapy, Recurrent Glioblastoma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Colorectal Cancer:
    Duration: 1 year(s)
    Documented Diagnosis Requirement: Explicitly Documented
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
    Documented Diagnosis: Yes
    Specialty Pharmacy is Required: Not Defined

    Kidney Cancer:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
    Supporting Documentation Requirements: Histology
    ECOG Score Requirement Included in Policy: N/A
    Policy Includes Reference to Coverage for Non Clear Cell Histology: Yes
    If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
    Concomitant Use With: 1 of Afinitor (everolimus);Erlotinib;Interferon Alfa

    Ovarian Cancer:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
    Concomitant Therapy Requirement: 1 of Chemotherapy;Olaparib
    Diagnosis Types: 4 of Adjuvant therapy;Advanced disease;as a single agent;As maintenance therapy as a single agent following recurrence therapy with chemotherapy plus bevacizumab;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance therapy;Maintenance therapy for stage II-IV disease if complete clinical remission or partial remission to primary therapy including bevacizumab as: a single agent or in combination with olaparib in patients BRCA1/2 wild-type or unknown;Metastatic disease;Recurrent disease;Refractory disease;Relapsed disease;Stage III or IV disease following initial surgical resection

  • Step Therapy: ST_APPLIES
  • Quantity Limit: limit maximum 240 EA PER 30 day(s)

  • For FAX form click HERE
    Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
     Log in to Surescripts
     Log in to CoverMyMeds; For details on drug coverage click HERE;