- Ovarian Cancer:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 2 of All FDA-approved indications;as a single agent;deleterious or suspected deleterious germline and/or somatic BRCA mutation;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance treatment after a complete or partial response to platinum-based chemotherapy;Treated with at least 2 prior lines chemotherapy;Treated with at least 2 prior lines of platinum based chemotherapy
Supporting Documentation Requirements: 2 of Chart Notes;Lab Tests
- PA_APPLIES
- Step Therapy: ST_APPLIES
- Quantity Limit: 204 lancets per 30 day(s).
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