- Prior Authorization: PA Applies
- Prior Authorization: PA_APPLIES
- Rheumatoid Arthritis (RA):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
- Endometrial Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Hepatocellular Carcinoma: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
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
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
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
Concomitant Use With: 1 of Afinitor (everolimus);Keytruda
Thyroid Carcinoma: Duration: 1 year(s)
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