- Quantity Limit: Maximum quantity 14 tablets per 21 day
- Prior Authorization: Cholangiocarcinoma:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Cholangiocarcinoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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