Health Net
Xalkori (crizotinib)
Drugs for Cancer : Drugs for Cancer
  • NSCLC ALK+ OR ROS1+ Disease:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Oncologist
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    NSCLC cMET Mutation:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

  • Anti-Cancer: Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
  • Prior Authorization: NSCLC ALK+ OR ROS1+ Disease:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 1 plan year

    NSCLC cMET Mutation:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes