- Prior Authorization: Chronic Lymphocytic Leukemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Follicular Lymphoma (FL): Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Prior Authorization: PA Applies
- Quantity Limit: limit maximum 10 ML PER fill retail
- Quantity Limit: limit maximum 30 day(s) supply
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