- Quantity Limit: limit maximum 3 EA PER fill retail
- Hepatocellular Carcinoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Duration of Reauthorization: = 12 month(s)
Diagnosis Types: 2 of Hepatocellular Cancer;Metastatic disease;Unresectable disease
ECOG Score Requirement Included in Policy: N/A
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
Concomitant Use With: 1 of Afinitor (everolimus);Keytruda
Thyroid Carcinoma:
Duration: 12 Month(s)
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