- 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
- PA Applies
- Available only through Specialty Pharmacy;
For FAX form click HERE Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites: Log in to Surescripts Log in to CoverMyMeds; For details on drug coverage click HERE;
- Prior Authorization: Documented Diagnosis: Yes
Duration: 1 year(s)
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