- Prior Authorization: Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Step Therapy: Graft Versus Host Disease (GVHD):
ST Single Generic
- Orally administered anticancer medication.
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Graft Versus Host Disease (GVHD):
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Myelofibrosis: Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 2 month(s)
Polycythemia Vera (PV): Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Variable
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