- Acute Lymphoblastic Leukemia:
Age Requirement: <= 25
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 2 of R/R CD19+ B-cell precursor ALL;R/R Ph+ B-ALL with refractory disease or greater than or equal to 2 relapses and failure of 2 TKIs;Relapsed/refractory Ph-, B-ALL with refractory disease or greater than or equal to 2 relapses
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Not Defined
Diffuse Large B-Cell Lymphoma:
Age Requirement: >= 18
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: No
Duration of Reauthorization: N/A
- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: <= 25
Duration: 3 Month(s)
Diffuse Large B-Cell Lymphoma:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
|