Health Net
Afinitor Disperz (everolimus (antineoplastic))
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Colorectal Cancer:
    Documented Diagnosis: Yes
    Age Requirement: >= 12
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Esophageal Cancer, Head and Neck Cancer, Hodgkin Lymphoma (HL), Kidney Cancer, Malignant Pleural Mesothelioma, Melanoma (MEL), Merkel Cell Carcinoma, Small Cell Lung Cancer, Uveal Melanoma:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Gastric Cancer:
    Age Requirement: >= 18
    Duration: 6 Month(s)

    Hepatocellular Carcinoma:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)

    NSCLC EGFR Mutated, NSCLC Systemic Therapy:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Tumor Mutational Burden-High (TMB-H) Cancer:
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Urothelial/Bladder Cancer:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Diabetes Type 2: GLP1 + Combo:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Supporting Documentation Requirements: Medication History

  • Quantity Limit: limit maximum 15 EA PER 30 day(s)