Prior authorization validity is provided when ALL of the following general and indication-specific criteria are met:
General requirement: Patient is at least 18 years of age (unless otherwise specified)>=18 yrs unless specified
Applies unless indication specifies different age
Central Precocious Puberty (CPP): Patient must have a contraindication, intolerance, or failure to Leupron Depot-Ped, Supprelin LA, AND Triptodur prior to consideration of Fensolvi; AND patient is less than 13 years of age; AND onset of secondary sexual characteristics earlier than age 8 for females and 9 for males associated with pubertal pituitary gonadotropin activation; AND diagnosis is confirmed by pubertal gonadal sex steroid levels and a pubertal LH response to stimulation by native GnRH; AND bone age advanced >2 SD beyond chronological age; AND tumor has been ruled out by appropriate imaging and hCG/labs; AND will not be used in combination with growth hormoneage <13; bone age >2 SD
HCPCS: J1950 and J1951
Endometriosis: Patient's diagnosis has been confirmed by a workup/evaluation (versus presumptive treatment)diagnostic confirmation required
HCPCS: J1950
Uterine Leiomyomata (fibroids): Patient's diagnosis has been confirmed by a workup/evaluation (versus presumptive treatment); AND patient is receiving iron therapydocumented iron therapy
HCPCS: J1950; initial authorization 3 months and non-renewable
Breast Cancer: Patient is a premenopausal woman with hormone receptor-positive disease used in combination with adjuvant endocrine therapy or for recurrent unresectable/stage IV disease; OR patient is male and used in combination with aromatase inhibitor therapypremenopausal status and receptor positivity or male sex
HCPCS: J9217 and J1950
Ovarian/Fallopian Tube/Primary Peritoneal Cancer: Used as a single agent for specified tumor types (e.g., stage II-IV granulosa cell tumors with relapse) or for specified epithelial/mucinous/clear cell/carcinosarcoma/grade 1 endometrioid histologies with persistent or recurrent disease; AND prior therapy with an aromatase inhibitor where requireddocumentation of tumor type and prior therapy where required
HCPCS: J9217 and J1950
Prostate Cancer: Patient must have a contraindication, intolerance, or failure to Camcevi, Eligard, AND Firmagon prior to consideration of Luprontrial/failure documentation required
HCPCS: J9217, J1952, J1954
Uterine Sarcoma (low-grade ESS or adenosarcoma): Patient is premenopausal and not suitable for surgery, with small tumor volume or indolent growth, and treatment used in combination with anastrozole/letrozole/exemestanesurgical unsuitability documented
HCPCS: J9217 and J1950
Head and Neck Cancer (salivary gland tumors): Used as a single agent or in combination with abiraterone + prednisone for androgen-receptor positive recurrent disease with distant metastases or unresectable locoregional recurrence/second primary with prior radiation therapyandrogen receptor positive recurrent disease
HCPCS: J9217, J1952, J1954
Prevention/Management of Menstrual Bleeding with HCT: Patient is premenopausal AND will receive myeloablative cytotoxic conditioning OR has menorrhagia due to thrombocytopenia related to delayed platelet engraftmentpremenopausal status and planned conditioning or thrombocytopenia-related menorrhagia
HCPCS: J1950; initial 6 months, non-renewable
Fertility Preservation During Chemotherapy: Patient is premenopausal, receiving cytotoxic chemotherapy with potential ovarian toxicity, AND has failed or is not a candidate for other fertility preservation methodsdocumentation of chemo regimen and failure/ineligibility for other methods
HCPCS: J1950; renewals possible while receiving chemo
Gender Dysphoria: Patient has experienced puberty development to at least Tanner stage 2 (if <18); AND diagnosis of gender dysphoria is confirmed by a qualified mental health professional or DSM-5-TR criteria; AND a qualified MHP has confirmed long‑lasting/intense dysphoria, worsening with puberty, coexisting issues addressed, and capacity for informed consent; AND patient informed of effects/side effects including fertility options and has given informed consent (with parental/guardian involvement when adolescent lacks legal medical consent); AND for adolescents a pediatric endocrinologist or clinician experienced in pubertal assessment has confirmed indication and absence of medical contraindicationsdocumented MHP evaluation and informed consent
HCPCS: J1950 and J1951