- Chronic Lymphocytic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
Concomitant Therapy Requirement: 1 of Acalabrutinib;bendamustine;chlorambucil;Venetoclax
Diagnosis Types: 1 of as a single agent for relapsed/refractory without 17p deletion;CLL with or without 17p deletion;first line in combination with chlorambucil for disease without deletion 17p/TP53 mutation;first line, as a single agent;Previously untreated CLL;Small Lymphocytic Lymphoma
Follicular Lymphoma (FL), Non Hodgkin Lymphoma (NHL): Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Nasal Polyposis:
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Prior Authorization: Acute Migraine:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Prior Authorization: PA Required
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