- Quantity Limit: 454 grams per 30 day(s).
- Cervical Cancer, Diabetic Retinopathy, Endometrial Cancer, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Malignant Pleural Mesothelioma, Neovascular (Wet) Age-Related Macular Degeneration (AMD), NSCLC Systemic Therapy, Recurrent Glioblastoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Colorectal Cancer: Duration: 1 year(s)
Documented Diagnosis Requirement: Explicitly Documented
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
Kidney Cancer: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
Supporting Documentation Requirements: Histology
ECOG Score Requirement Included in Policy: N/A
Policy Includes Reference to Coverage for Non Clear Cell Histology: Yes
If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
Concomitant Use With: 1 of Afinitor (everolimus);Erlotinib;Interferon Alfa
Ovarian Cancer: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
Concomitant Therapy Requirement: 1 of Chemotherapy;Olaparib
Diagnosis Types: 4 of Adjuvant therapy;Advanced disease;as a single agent;As maintenance therapy as a single agent following recurrence therapy with chemotherapy plus bevacizumab;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance therapy;Maintenance therapy for stage II-IV disease if complete clinical remission or partial remission to primary therapy including bevacizumab as: a single agent or in combination with olaparib in patients BRCA1/2 wild-type or unknown;Metastatic disease;Recurrent disease;Refractory disease;Relapsed disease;Stage III or IV disease following initial surgical resection
- Quantity Limit: limit maximum 1 EA PER 300 day(s)
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