- Acute Lymphoblastic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Diagnosis Types: Acute lymphoblastic leukemia
ECOG Score Requirement Included in Policy: N/A
Contraindications: Pancreatitis, thrombosis, hemorrhagic events
Specialty Pharmacy is Required: Y
- May be covered under Medical Benefit.
- Prior Authorization: Cytomegalovirus (CMV):
Duration: 1 year(s)
- Quantity Limit: 204 strips per 30 day(s).
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