Health Net
Afinitor (everolimus (antineoplastic))
Drugs for Cancer : Drugs for Cancer
  • Step Therapy: Neuroendocrine Tumor (NET):
    ST Single Generic

  • 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: 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: 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), Kidney Cancer:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    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