- NSCLC Systemic Therapy:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Small Cell Lung Cancer:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
ECOG Score Requirement Included in Policy: N/A
Diagnosis Types: 3 of First line treatment;No previous therapy with a programmed death (PD-1/PD-L1)-directed therapy;Small Cell Lung Cancer
Concomitant Therapy Requirement: 1 of carboplatin and etoposide;cisplatin and etopside
- Prior Authorization: Cluster Headache:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Migraine Prevention:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
- Quantity Limit: 3 pump bottles per 30 day(s).
- Quantity Limit: 6 vials per 28 day(s).
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