Anthem Blue Cross (HMO, PPO, EPO) |
Lartruvo (olaratumab) |
Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
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;
- Soft Tissue Sarcoma:
Duration: 1 year(s)
Reauthorization Required: No
Medical Test Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 2 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 3 of No previous therapy with anthracyclines or anthracenediones;Recurrent or metastatic disease;Soft tissue sarcoma
Physician attestation of diagnostic or lab test required: No
Concomitant Therapy Requirement: doxorubicin
ECOG Score Requirement Included in Policy: <= 2
Supporting Documentation Requirements: Histology
Documented Diagnosis: Yes
- PA Applies
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