- Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
- Acute Lymphoblastic Leukemia:
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Drug Policy Based On: 2 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 2 of All FDA-approved indications;Ph+ ALL;PH+/BCR-ABL+
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Not Defined
Chronic Myelogenous Leukemia: Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Gastrointestinal Stromal Tumor: Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Soft Tissue Sarcoma: Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Specialist Type(s): 1 of Oncologist
Reauthorization Required: No
Medical Test Required: No
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of ACCC;AHFS Guidelines;Clinical Pharmacology;Elsevier/Gold Standard Clinical Pharmacology;FDA Approved Indications;Micromedex;NCCN Guidelines;United States Pharmacopeia (USP);Wolters Kluwer Lexi-Drugs
Diagnosis Types: 1 of Gastrointestinal stromal tumor (GIST);Soft tissue sarcoma
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: No
- Step Therapy: ST Single Generic
- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
Chronic Myelogenous Leukemia: Documented Diagnosis: Yes
Reauthorization Required: Yes
Gastrointestinal Stromal Tumor: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Soft Tissue Sarcoma: Age Requirement: >= 18
Duration: 1 plan year
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