- PA Applies
- Kidney Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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
- Minimum Age: 3 Years; Maximum Age: N.A.;
- Quantity Limit: 8 patches per 28 day(s).
- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
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