- 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: Payer Specific
Diagnosis Types: 1 of Chronic Lymphocytic Leukemia;Small Lymphocytic Lymphoma
Diffuse Large B-Cell Lymphoma:
Age Requirement: >= 19
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Follicular Lymphoma (FL):
Age Requirement: < 19
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Graft Versus Host Disease (GVHD), Mantle Cell Lymphoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Marginal Zone Lymphoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: = 12 month(s)
Non Hodgkin Lymphoma (NHL):
Age Requirement: <= 19
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: < 12 month(s)
Waldenstrom Macroglobulinemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Avella Specialty Pharmacy
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Prior Authorization: Chronic Lymphocytic Leukemia, Graft Versus Host Disease (GVHD), Mantle Cell Lymphoma, Waldenstrom Macroglobulinemia:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Diffuse Large B-Cell Lymphoma:
Documented Diagnosis: Yes
Age Requirement: >= 19
Duration: 12 Month(s)
Reauthorization Required: Yes
Follicular Lymphoma (FL):
Documented Diagnosis: Yes
Age Requirement: < 19
Duration: 12 Month(s)
Reauthorization Required: Yes
Marginal Zone Lymphoma:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Non Hodgkin Lymphoma (NHL):
Documented Diagnosis: Yes
Age Requirement: <= 19
Duration: 12 Month(s)
Reauthorization Required: Yes
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