- Prior Authorization: Acute Lymphoblastic Leukemia, Aggressive Systemic Mastocytosis (ASM):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Chronic Myelogenous Leukemia, Gastrointestinal Stromal Tumor: Documented Diagnosis: Yes
Duration: 1 year(s)
- Acute Lymphoblastic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of Clinical Pharmacology;NCCN Guidelines
Diagnosis Types: Ph+ ALL
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Not Defined
Aggressive Systemic Mastocytosis (ASM): Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Chronic Myelogenous Leukemia, Gastrointestinal Stromal Tumor: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Quantity Limit: 2 tablets per 1 day(s).
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location;
For FAX form click HERE Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites: Log in to Surescripts Log in to CoverMyMeds; For details on drug coverage click HERE;
- PA Applies
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