- Orally administered anticancer medication.
- Quantity Limit: limit maximum 3 EA PER 1 day(s)
- Urothelial/Bladder Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
Diagnosis Types: 3 of disease progression during or following platinum-containing chemotherapy;FGFR3 or FGFR2 mutation-positive as detected by an FDA approved test;Locally advanced or metastatic urothelial carcinoma;Progression within 12 mos. of neoadjuvant or adjuvant treatment with platinum-containing regimen
ECOG Score Requirement Included in Policy: N/A
- Prior Authorization: Urothelial/Bladder Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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