- Prior Authorization: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Orally administered anticancer medication.
- Chronic Lymphocytic Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
Diagnosis Types: 1 of Chronic Lymphocytic Leukemia;Small Lymphocytic Lymphoma
Follicular Lymphoma (FL):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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