- Acute Lymphoblastic Leukemia:
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 Clinical Pharmacology;NCCN Guidelines
Diagnosis Types: Ph+ ALL
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Not Defined
Aggressive Systemic Mastocytosis (ASM):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Chronic Myelogenous Leukemia, Gastrointestinal Stromal Tumor:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
|