- Prior Authorization: Acute Lymphoblastic Leukemia, Gastrointestinal Stromal Tumor:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Chronic Myelogenous Leukemia, Soft Tissue Sarcoma: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- PA_APPLIES
- Anti-Cancer:Maximum $200 copayment per State Law.
For FAX form click HERE Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites: Log in to Surescripts Log in to CoverMyMeds; For details on drug coverage click HERE;
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