- Limited Access. Must use AcariaHealth Specialty Rx. Anti-Cancer: Maximum $200 copayment per State Law.
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Gastrointestinal Stromal Tumor:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Hepatocellular Carcinoma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Kidney Cancer:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- Step Therapy: ST Single Generic
- Acute Myeloid Leukemia:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 3 of Chart Notes;FLT3 mutation as detected by an FDA-approved test;Lab Tests
Quantity Limit: N/A
Criteria for Reauthorization: Member is responding positively to therapy
Use of Biomarkers in Policy: FLT3 mutation
Diagnosis Types: 2 of As a single agent for maintenance therapy when in remission post-allogenic stem cell transplantation;FLT3 mutation-positive AML detected by FDA-approved test;in combination with either azacitidine, decitabine, or cytarabine
Excludes Coverage in Maintenance Setting: No
Gastrointestinal Stromal Tumor:
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)
Hepatocellular Carcinoma:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Duration of Reauthorization: = 1 plan year
Diagnosis Types: 1 of All FDA-approved indications;Hepatocellular Cancer;Unresectable disease
ECOG Score Requirement Included in Policy: N/A
Child-Pugh Score Required for Treatment: Class A (5-6)
Kidney Cancer:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
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
Soft Tissue Sarcoma:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Medical Test Required: No
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: NCCN Guidelines
Diagnosis Types: 1 of Gastrointestinal stromal tumor (GIST);Soft tissue sarcoma
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
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