Health Net
Yervoy (ipilimumab)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Hepatocellular Carcinoma:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 16 week(s)

    Kidney Cancer:
    Documented Diagnosis: Yes
    Age Requirement: >= 12
    Duration: 16 week(s)

    Malignant Pleural Mesothelioma, NSCLC Systemic Therapy:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Melanoma (MEL), Uveal Melanoma:
    Documented Diagnosis: Yes
    Age Requirement: >= 12
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • 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)

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