- Step Therapy: ST_APPLIES
- Ovarian Cancer:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Unspecified
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Drug Policy Based On: 1 of Micromedex;NCCN Guidelines
Diagnosis Types: 1 of All medically accepted indications;All NCCN indications with evidence level of 2A or higher
Supporting Documentation Requirements: Chart Notes
Small Cell Lung Cancer: Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
ECOG Score Requirement Included in Policy: N/A
Diagnosis Types: 2 of Small Cell Lung Cancer;Unspecified
- Prior Authorization: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 30 day(s) supply
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