- Anti-Cancer:Maximum $200 copayment per State Law.
- Prior Authorization: Chronic Lymphocytic Leukemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Mantle Cell Lymphoma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- Step Therapy: Chronic Lymphocytic Leukemia:
ST Single Generic
- Chronic Lymphocytic Leukemia:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
Concomitant Therapy Requirement: obinutuzumab
Diagnosis Types: 2 of as a single agent;Chronic Lymphocytic Leukemia;CLL for relapsed/refractory disease;patients with CLL who have received at least one prior therapy;Small Lymphocytic Lymphoma
Mantle Cell Lymphoma:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
|