- Anti-Cancer:Maximum $200 copayment per State Law.
- Prior Authorization: Chronic Lymphocytic Leukemia, Marginal Zone Lymphoma, Non Hodgkin Lymphoma (NHL):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Follicular Lymphoma (FL):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Step Therapy: Marginal Zone Lymphoma:
ST Single Generic
- Chronic Lymphocytic Leukemia:
Age Requirement: >= 18
Duration: 6 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)
Drug Policy Based On: FDA Approved Indications
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
Diagnosis Types: 1 of CLL for relapsed/refractory disease;Small Lymphocytic Lymphoma
Follicular Lymphoma (FL):
Duration: 6 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)
Marginal Zone Lymphoma:
Age Requirement: >= 18
Duration: 6 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)
Non Hodgkin Lymphoma (NHL):
Age Requirement: >= 18
Duration: 6 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)
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