- Prior Authorization: PA_APPLIES
- Acute Lymphoblastic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Diagnosis Types: Acute lymphoblastic leukemia
ECOG Score Requirement Included in Policy: N/A
Contraindications: Pancreatitis, thrombosis, hemorrhagic events
Specialty Pharmacy is Required: Y
- Preventive Drug: $0 copay. Grand Fathered Plans at Tier 2;
- PA_APPLIES
- Step Therapy: Psychiatry: Schizophrenia:
ST Single Generic
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