- Prior Authorization: Beta Thalassemia Anemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
Myelodysplastic Syndrome:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Limited Access. Must use AcariaHealth Specialty Rx. Anti-Cancer:Maximum $200 copayment per State Law.
- Prior Authorization: Antiviral: Hepatitis C (HCV):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 week(s)
Reauthorization Required: Yes
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