- 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)
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