- Acute Lymphoblastic Leukemia:
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
Diagnosis Types: Acute lymphoblastic leukemia
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Not Defined
- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
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