- Prior Authorization: Breast Cancer: Triple Negative, Cutaneous Squamous Cell Carcinoma (cSCC), Head and Neck Cancer, Hepatocellular Carcinoma, Hodgkin Lymphoma (HL), Kidney Cancer, Malignant Pleural Mesothelioma, Metastatic Prostate Cancer, Urothelial/Bladder Cancer, Uveal Melanoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
Cervical Cancer, Endometrial Cancer, Esophageal Cancer, Melanoma (MEL), Merkel Cell Carcinoma, NSCLC EGFR Mutated, NSCLC Systemic Therapy, Solid Tumor with deficient mismatch repair (dMMR):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Gastric Cancer:
Duration: 1 year(s)
Tumor Mutational Burden-High (TMB-H) Cancer:
Medical Test Required: Yes
Duration: 1 year(s)
- 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;
- PA Applies
- Breast Cancer: Triple Negative, Cutaneous Squamous Cell Carcinoma (cSCC), Head and Neck Cancer, Hodgkin Lymphoma (HL), Malignant Pleural Mesothelioma, Metastatic Prostate Cancer, Uveal Melanoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Cervical Cancer, Endometrial Cancer, Esophageal Cancer, Melanoma (MEL), NSCLC EGFR Mutated, NSCLC Systemic Therapy, Solid Tumor with deficient mismatch repair (dMMR):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Gastric Cancer:
Duration: 1 year(s)
Hepatocellular Carcinoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Duration of Reauthorization: N/A
Diagnosis Types: 6 of Advanced disease;as a single agent;Hepatocellular Cancer;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;not receiving therapy with a systemic immunosuppressant;patients who have received at least one prior therapy
Child-Pugh Score Required for Treatment: 1 of Class A (5-6)
Kidney 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
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
Concomitant Use With: 1 of Inlyta;Lenvima
Merkel Cell Carcinoma:
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
Diagnosis Types: 4 of Advanced disease;as a single agent;Merkel Cell Carcinoma;metastatic;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Recurrent local/regional disease
Tumor Mutational Burden-High (TMB-H) Cancer:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
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: 4 of as a single agent;disease progression during or following platinum-containing chemotherapy;In patients who are not eligible for any platinum-containing chemotherapy;Locally advanced or metastatic urothelial carcinoma;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Not eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1;Progression within 12 mos. of neoadjuvant or adjuvant treatment with platinum-containing regimen;subsequent therapy
ECOG Score Requirement Included in Policy: <= 2
Individual cannot have a diagnosis of any of the following: 1 of History of severe autoimmune disease;Other;Require systemic immunosuppression
|