- Prior Authorization: PA_APPLIES
- Neurogenic Detrusor Overactivity (NDO):
Age Requirement: >= 3
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Acute Lymphoblastic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Diagnosis Types: 2 of as a single agent;CD19+ B-cell precursor ALL;First or second complete remission B-cell precursor type. MRD is greater than or equal to 0.1%;R/R CD19+ B-cell precursor ALL
ECOG Score Requirement Included in Policy: N/A
Contraindications: Active CNS malignancy involvement
Specialty Pharmacy is Required: Y
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