- Step Therapy Applies
- Quantity Limit: limit maximum 6 EA PER 1 day(s)
- Prior Authorization: Colorectal Cancer:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Melanoma (MEL):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Orally administered anticancer medication.
- Colorectal Cancer:
Duration: 12 Month(s)
Documented Diagnosis Requirement: Explicitly Documented
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: Payer Specific
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
Melanoma (MEL):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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