Anthem Blue Cross (HMO, PPO, EPO)
Hycamtin (topotecan)
Drugs for Cancer : Drugs for Cancer
  • Quantity Limit: limit maximum 8 EA PER 1 day(s)
  • Prior Authorization: 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

    Ovarian 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
    Diagnosis Types: 2 of epithelial ovarian, fallopian tube, or primary peritoneal cancer;persistent or recurrent disease

    Soft Tissue Sarcoma:
    Duration: 12 Month(s)
    Reauthorization Required: Yes
    Medical Test Required: No
    Duration of Reauthorization: = 12 month(s)
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Diagnosis Types: 1 of Alveolar soft part sarcoma;Angiosarcoma;Extremity/superficial trunk, head/neck sarcoma;Gastrointestinal stromal tumor (GIST);Pleomorphic rhabdomyosarcoma;Recurrent or metastatic disease;Retroperitoneal/intra-abdominal sarcoma;Solitary fibrous tumor/hemangiopericytoma
    Physician attestation of diagnostic or lab test required: No
    ECOG Score Requirement Included in Policy: N/A
    Documented Diagnosis: Yes

    Thyroid Carcinoma:
    Duration: 12 Month(s)

  • Preventive Drug: Zero copay.