- Prior Authorization: Cervical Cancer, Colorectal Cancer, Kidney Cancer, NSCLC Systemic Therapy, Ovarian Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Endometrial Cancer, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Recurrent Glioblastoma:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: 800 grams per 28 day(s).
|