- Aggressive Systemic Mastocytosis (ASM), Chronic Myelogenous Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Gastrointestinal Stromal Tumor:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): BriovaRx
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Prior Authorization: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 8 EA PER 1 day(s)
- Orally administered anticancer medication.
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