- PA_APPLIES
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: < 19
Duration: 12 Month(s)
Reauthorization Required: Yes
Aggressive Systemic Mastocytosis (ASM):
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Prior Authorization: PA_APPLIES
- Hyperkalemia:
Age Requirement: >= 18
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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