- Acute Myeloid Leukemia:
Age Requirement: >= 18
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Supporting Documentation Requirements: Documented rationale showing inability to use IV or SQ formulation
Quantity Limit: N/A
Diagnosis Types: Continued treatment of acute myeloid leukemia after first complete remission (CR) or complete remission with incomplete blood count recovery (CRi) following intensive induction chemotherapy and unable to complete intensive curative therapy
Excludes Coverage in Maintenance Setting: No
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
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