Health Net
Stivarga (regorafenib)
Drugs for Cancer : Drugs for Cancer
  • 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)