- PA_APPLIES
- Quantity Limit: 204 strips per 30 day(s).
- Prior Authorization: Graft Versus Host Disease (GVHD):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 12 Month(s)
Reauthorization Required: Yes
Myelofibrosis: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Polycythemia Vera (PV): Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- Orally administered anticancer medication.
Zero copay may apply.
Must be 35 or older and at increased risk for the first occurrence of breast cancer - after risk assessment and counseling.
|