- Orally administered anticancer medication.
- Prior Authorization: Gastrointestinal Stromal Tumor, Kidney Cancer, Neuroendocrine Tumor (NET), Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Thyroid Carcinoma:
Duration: 12 Month(s)
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Gastrointestinal Stromal Tumor, Neuroendocrine Tumor (NET):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Kidney Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
ECOG Score Requirement Included in Policy: N/A
Policy Includes Reference to Coverage for Non Clear Cell Histology: No
If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
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;Alveolar soft part sarcoma;Angiosarcoma;Gastrointestinal stromal tumor (GIST);Solitary fibrous tumor/hemangiopericytoma
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
Thyroid Carcinoma:
Duration: 12 Month(s)
- Step Therapy: Thyroid Carcinoma:
ST Single Brand
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