- Quantity Limit: 4 tablets per 1 day(s).
- Kidney Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
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
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 2 of Alveolar soft part sarcoma;Angiosarcoma;as a single agent;Extremity/superficial trunk, head/neck sarcoma;Gastrointestinal stromal tumor (GIST);Pleomorphic rhabdomyosarcoma;Rhabdomyosarcoma;Soft tissue sarcoma;Solitary fibrous tumor/hemangiopericytoma
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)
- PA Applies
- 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;
- Step Therapy: Thyroid Carcinoma:
ST Single Brand
- Prior Authorization: Kidney Cancer, Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
Thyroid Carcinoma:
Duration: 1 year(s)
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