- Colorectal Cancer:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis Requirement: Explicitly Documented
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: Payer Specific
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
Gastrointestinal Stromal Tumor: 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
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: Unspecified
Diagnosis Types: 3 of All FDA-approved indications;as a single agent;Hepatocellular Cancer;NCCN recommended level 2a-b or better;subsequent therapy
ECOG Score Requirement Included in Policy: N/A
Child-Pugh Score Required for Treatment: Class A (5-6)
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: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 1 of Angiosarcoma;Soft tissue sarcoma;Solitary fibrous tumor/hemangiopericytoma
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
- Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
- Prior Authorization: Colorectal Cancer, Gastrointestinal Stromal Tumor, Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Hepatocellular Carcinoma: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
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