UnitedHealthcare
Stivarga (regorafenib)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Colorectal Cancer:
    Documented Diagnosis: Yes
    Age Requirement: < 19
    Duration: 12 Month(s)
    Reauthorization Required: Yes

    Gastrointestinal Stromal Tumor, Hepatocellular Carcinoma:
    Documented Diagnosis: Yes
    Duration: 12 Month(s)

    Soft Tissue Sarcoma:
    Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Colorectal Cancer:
    Age Requirement: < 19
    Duration: 12 Month(s)
    Documented Diagnosis Requirement: Explicitly Documented
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Documented Diagnosis: Yes
    Specialty Pharmacy is Required: Not Defined

    Gastrointestinal Stromal Tumor:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Hepatocellular Carcinoma:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Duration of Reauthorization: = 12 month(s)
    Diagnosis Types: 2 of For patients who received previous treatment with Nexavar/sorafenib;Hepatocellular Cancer
    ECOG Score Requirement Included in Policy: N/A

    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 All FDA-approved indications;Extremity/superficial trunk, head/neck sarcoma;Gastrointestinal stromal tumor (GIST);Pleomorphic rhabdomyosarcoma;Recurrent or metastatic disease;Retroperitoneal/intra-abdominal sarcoma;Unresectable or metastatic
    Physician attestation of diagnostic or lab test required: No
    ECOG Score Requirement Included in Policy: N/A
    Documented Diagnosis: Yes

  • Orally administered anticancer medication.
  • Quantity Limit: limit maximum 3 EA PER 1 day(s)