- Step Therapy: Ovarian Cancer:
ST Generic and Brand
- Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
- Prior Authorization: Ovarian Cancer:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Small Cell Lung Cancer:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Ovarian Cancer:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Unspecified
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Drug Policy Based On: 1 of Micromedex;NCCN Guidelines
Diagnosis Types: 1 of All medically accepted indications;All NCCN indications with evidence level of 2A or higher
Supporting Documentation Requirements: Chart Notes
Small Cell Lung Cancer:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
ECOG Score Requirement Included in Policy: N/A
Diagnosis Types: 2 of Small Cell Lung Cancer;Unspecified
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