- Prior Authorization: Myelodysplastic Syndrome:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: Maximum quantity 5 tablets per month.
- Myelodysplastic Syndrome:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
|