- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location;
For FAX form click HERE Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites: Log in to Surescripts Log in to CoverMyMeds; For details on drug coverage click HERE;
- PA Applies
- Acute Myeloid Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
Supporting Documentation Requirements: FLT3 mutation as detected by an FDA-approved test
Quantity Limit: N/A
Use of Biomarkers in Policy: FLT3 mutation
Diagnosis Types: 2 of FLT3 mutation-positive AML detected by FDA-approved test;Post Remission Therapy;Relapsed/Refractory acute myeloid leukemia
Excludes Coverage in Maintenance Setting: No
Gastrointestinal Stromal Tumor: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Hepatocellular Carcinoma: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Unspecified
Duration of Reauthorization: N/A
Diagnosis Types: 2 of Advanced disease;Hepatocellular Cancer;Unresectable disease
ECOG Score Requirement Included in Policy: N/A
Kidney Cancer: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Unspecified
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
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: Duration: 1 year(s)
Reauthorization Required: No
Medical Test Required: No
Specialty Pharmacy Provider(s): Unspecified
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
Diagnosis Types: Soft tissue sarcoma
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
Thyroid Carcinoma: Duration: 1 year(s)
- Quantity Limit: 4 tablets per 1 day(s).
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Gastrointestinal Stromal Tumor, Hepatocellular Carcinoma, Kidney Cancer, Soft Tissue Sarcoma: Documented Diagnosis: Yes
Duration: 1 year(s)
Thyroid Carcinoma: Duration: 1 year(s)
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