- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Chronic Myelogenous Leukemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Anti-Cancer: Maximum $200 copayment per State Law.
- Acute Lymphoblastic Leukemia:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: PH+/BCR-ABL+
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Not Defined
Chronic Myelogenous Leukemia:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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