- Quantity Limit: limit maximum 120 ML PER 28 day(s)
- Prior Authorization: Chemo-induced Nausea and Vomiting (CINV):
Documented Diagnosis: Yes
Duration: 12 Month(s)
HIV Wasting:
Duration: 12 Month(s)
- Chemo-induced Nausea and Vomiting (CINV):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
NV associated with highly emetogenic cancer chemotherapy (HEC): No
NV associated with moderately emetogenic cancer chemotherapy (MEC): No
Concomitant therapy with Corticosteroid: No
Concomitant therapy with 5-HT3 Antagonist: No
HIV Wasting:
Duration: 12 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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