- PA Applies
- Esophageal Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
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: 5 of as a single agent;For patients who received previous treatment with Nexavar/sorafenib;Hepatocellular Cancer;Metastatic disease;Patients who have an alpha fetoprotein (AFP) of >=400 ng/mL
ECOG Score Requirement Included in Policy: N/A
NSCLC EGFR Mutated:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
NSCLC Systemic Therapy:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
- Prior Authorization: Esophageal Cancer, Hepatocellular Carcinoma, NSCLC Systemic Therapy:
Documented Diagnosis: Yes
Duration: 1 year(s)
Gastric Cancer:
Duration: 1 year(s)
NSCLC EGFR Mutated:
Documented Diagnosis: Yes
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;
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