- 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.
|