Health Net
Cyramza (ramucirumab)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Colorectal Cancer, Esophageal Cancer, NSCLC EGFR Mutated, NSCLC Systemic Therapy:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Gastric Cancer:
    Age Requirement: >= 18
    Duration: 6 Month(s)

    Hepatocellular Carcinoma:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)

  • Colorectal Cancer:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis Requirement: Explicitly Documented
    Medical Test Required: No
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Drug Policy Based On: FDA Approved Indications
    Documented Diagnosis: Yes
    Specialty Pharmacy is Required: Not Defined

    Esophageal Cancer, NSCLC EGFR Mutated, NSCLC Systemic Therapy:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Gastric Cancer:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes

    Hepatocellular Carcinoma:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Oncologist
    Duration of Reauthorization: = 12 month(s)
    Diagnosis Types: 4 of All FDA-approved indications;For patients who received previous treatment with Nexavar/sorafenib;Hepatocellular Cancer;Patients who have an alpha fetoprotein (AFP) of >=400 ng/mL;Progressive disease
    ECOG Score Requirement Included in Policy: N/A