UnitedHealthcare
Oseni (alogliptin-pioglitazone)
Hormones : Drugs for Diabetes
  • Cervical Cancer, Diabetic Retinopathy, Endometrial Cancer, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Malignant Pleural Mesothelioma, Neovascular (Wet) Age-Related Macular Degeneration (AMD), NSCLC Systemic Therapy, Recurrent Glioblastoma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Colorectal Cancer:
    Duration: 1 year(s)
    Documented Diagnosis Requirement: Explicitly Documented
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
    Documented Diagnosis: Yes
    Specialty Pharmacy is Required: Not Defined

    Kidney Cancer:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
    Supporting Documentation Requirements: 2 of Histology;Medication History
    ECOG Score Requirement Included in Policy: N/A
    Policy Includes Reference to Coverage for Non Clear Cell Histology: Yes
    If Non-Clear Cell Histology is Referenced in Policy is There a Trial and Failure Requirement: No
    Concomitant Use With: 1 of Afinitor (everolimus);Erlotinib;Interferon Alfa

    Ovarian Cancer:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of NCCN Guidelines;Payer Specific
    Concomitant Therapy Requirement: 1 of Chemotherapy;Olaparib
    Diagnosis Types: 4 of Adjuvant therapy;Advanced disease;as a single agent;As maintenance therapy as a single agent following recurrence therapy with chemotherapy plus bevacizumab;epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance therapy;Maintenance therapy for stage II-IV disease if complete clinical remission or partial remission to primary therapy including bevacizumab as: a single agent or in combination with olaparib in patients BRCA1/2 wild-type or unknown;Metastatic disease;Recurrent disease;Refractory disease;Relapsed disease;Stage III or IV disease following initial surgical resection
    Supporting Documentation Requirements: Medication History