- Quantity Limit: limit maximum 37 EA PER 30 day(s)
- Acute Myeloid Leukemia:
Is Medicare B vs D: No
Specialist Required: Yes
Unspecified PA: No
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: Payer Specific
Supporting Documentation Requirements: Unspecified
Quantity Limit: N/A
Criteria for Reauthorization: 2 of Member is responding positively to therapy;Patient must meet initial criteria
Use of Biomarkers in Policy: CD33 mutation
Diagnosis Types: 2 of CD33-positive acute myeloid leukemia;Newly diagnosed acute myeloid leukemia;Relapsed/Refractory acute myeloid leukemia;Single agent use in the scenario of Default
Diagnosis Types: 2 of CD33-positive acute myeloid leukemia;Newly diagnosed acute myeloid leukemia in the scenario of Newly diagnosed treatment
Diagnosis Types: 2 of CD33-positive acute myeloid leukemia;Relapsed/Refractory acute myeloid leukemia in the scenario of Relapsed/Refractory
Excludes Coverage in Maintenance Setting: No
- Prior Authorization: Hemophilia A (Factor VIII):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
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