- PA Applies
- Prior Authorization: Breast Cancer: Triple Negative, Hepatocellular Carcinoma, Melanoma (MEL), NSCLC EGFR Mutated, NSCLC Systemic Therapy, Small Cell Lung Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Urothelial/Bladder Cancer:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Breast Cancer: Triple Negative:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: No
Duration of Reauthorization: N/A
Hepatocellular Carcinoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration of Reauthorization: N/A
Diagnosis Types: 4 of advanced or metastatic hepatocellular carcinoma;has not received treatment with another PD-1 agent;Hepatocellular Cancer;not receiving therapy with a systemic immunosuppressant;Unresectable disease
ECOG Score Requirement Included in Policy: <= 2
Child-Pugh Score Required for Treatment: Class A (5-6)
Melanoma (MEL), NSCLC EGFR Mutated, NSCLC Systemic Therapy:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Small Cell Lung Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
ECOG Score Requirement Included in Policy: N/A
Diagnosis Types: 2 of has not received treatment with another PD-1 agent;Small Cell Lung Cancer
Concomitant Therapy Requirement: carboplatin and etoposide
Urothelial/Bladder Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Diagnosis Types: 3 of disease progression during or following platinum-containing chemotherapy;in patients who are not eligible for cisplatin-containing chemotherapy ;Locally advanced or metastatic urothelial carcinoma;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Progression within 12 mos. of neoadjuvant or adjuvant treatment with platinum-containing regimen
ECOG Score Requirement Included in Policy: <= 2
Individual cannot have a diagnosis of any of the following: 1 of History of severe autoimmune disease;Require systemic immunosuppression
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
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