| Western Health Advantage - All plan years |
| Koselugo (selumetinib-vitamin E TPGS) |
| Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: 1 tablet per 1 day(s).
- Step Therapy: ST_APPLIES
- Diabetic Medical Supplies:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Prior Authorization: Pain Narcotic: Opioid:
Documented Diagnosis: Yes
Duration: 3 Month(s)
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