- Preventive Drug: Zero copay.
- 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: 1 of bendamustine and rituximab;obinutuzumab;rituximab
Diagnosis Types: 2 of as a single agent;Chronic Lymphocytic Leukemia;Small Lymphocytic Lymphoma
Diffuse Large B-Cell Lymphoma:
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: N/A
Follicular Lymphoma (FL):
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: No
Duration of Reauthorization: N/A
Graft Versus Host Disease (GVHD):
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Bone Marrow Specialist;Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Mantle Cell Lymphoma:
Age Requirement: >= 18
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Marginal Zone Lymphoma:
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: Unspecified
Non Hodgkin Lymphoma (NHL):
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Waldenstrom Macroglobulinemia:
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: <= 12 month(s)
- Quantity Limit: 113 gram per 1 day(s).
- Step Therapy: Pain Narcotic: Opioid:
ST Multiple Brands
|