- 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
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