- 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)
- Prior Authorization: Amyotrophic Lateral Sclerosis (ALS):
Documented Diagnosis: Yes
Duration: 12 Month(s)
- PA Applies
- Prior Authorization: PA_APPLIES
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