- Chronic Lymphocytic Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: Payer Specific
Supporting Documentation Requirements: Lab Tests
Diagnosis Types: 1 of CLL for relapsed/refractory disease;Small Lymphocytic Lymphoma
Mantle 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)
- Prior Authorization: Chronic Lymphocytic Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Mantle Cell Lymphoma:
Documented Diagnosis: Yes
Age Requirement: > 19
Duration: 12 Month(s)
Reauthorization Required: Yes
- Orally administered anticancer medication.
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
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