- Prior Authorization: Ovarian Cancer:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Ovarian Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: Payer Specific
Concomitant Therapy Requirement: bevacizumab (Avastin)
Diagnosis Types: 2 of Advanced disease;Advanced ovarian, fallopian tube or primary peritoneal cancers after 3 or more prior chemo regimens with HRD+ mutations by deleterious or suspected deleterious BRCA mutation or genomic instability and progression >6 months after response to the last platinum-based therapy;deleterious or suspected deleterious germline and/or somatic BRCA mutation;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance treatment after a complete or partial response to platinum-based chemotherapy;Patients who have been treated with three or more prior lines of chemotherapy;persistent or recurrent disease;Platinum-sensitive
- Orally administered anticancer medication.
- Quantity Limit: limit maximum 3 EA PER 1 day(s)
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