Health Net
Lonsurf (trifluridine-tipiracil)
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: 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
    Documented Diagnosis: Yes
    Specialty Pharmacy is Required: Not Defined

    Gastric Cancer:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes

  • Anti-Cancer:Maximum $200 copayment per State Law.
  • Prior Authorization: Colorectal Cancer:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

    Gastric Cancer:
    Age Requirement: >= 18
    Duration: 1 plan year