- Hepatocellular Carcinoma:
Age Requirement: >= 18
Duration: 16 week(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Duration of Reauthorization: N/A
Diagnosis Types: 2 of All FDA-approved indications;For patients who received previous treatment with Lenvima;For patients who received previous treatment with Nexavar/sorafenib;Hepatocellular Cancer
ECOG Score Requirement Included in Policy: N/A
Child-Pugh Score Required for Treatment: Class A (5-6)
Kidney Cancer: Age Requirement: >= 12
Duration: 16 week(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of ACCC;AHFS Guidelines;Clinical Pharmacology;Elsevier/Gold Standard Clinical Pharmacology;FDA Approved Indications;Micromedex;NCCN Guidelines;United States Pharmacopeia (USP);Wolters Kluwer Lexi-Drugs
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
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: Opdivo
Malignant Pleural Mesothelioma: 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)
Melanoma (MEL), Uveal Melanoma: Age Requirement: >= 12
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)
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: >= 2 year(s)
- Quantity Limit: limit maximum 30 day(s) supply
- Step Therapy: CIDP: Immune Globulin:
ST Generic and Brand
PID: Immune Globulin: ST Single Brand
- Prior Authorization: Ovarian Cancer:
Documented Diagnosis: Yes
Duration: 1 year(s)
- PV $0 Co pay Grand Fathered Plans at Tier 2
- Quantity Limit: 204 lancets per 30 day(s).
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