- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Chronic Myelogenous Leukemia:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- PA Required
- Derm: Acne Vulgaris:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Limited to non-cosmetic use: No
- Prior Authorization: Diabetic Medical Supplies:
Duration: 1 year(s)
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