Western Health Advantage
Byetta 5 MCG Pen (exenatide)
Hormones : Drugs for Diabetes
  • Breast Cancer: Triple Negative:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Urothelial/Bladder Cancer:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Diagnosis Types: 3 of Advanced disease;Metastatic disease;Previous treatment with a PD-1/PDL-1 inhibitor and platinum-containing chemotherapy;Urothelial carcinoma
    ECOG Score Requirement Included in Policy: N/A

  • Quantity Limit: limit maximum 60 EA PER 30 day(s)
  • Quantity Limit: limit maximum 4 EA PER 30 day(s)
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