- Prior Authorization: Colorectal Cancer:
Documented Diagnosis: Yes
Age Requirement: < 19
Duration: 12 Month(s)
Reauthorization Required: Yes
Gastric Cancer:
Age Requirement: < 19
Duration: 12 Month(s)
- Colorectal Cancer:
Age Requirement: < 19
Duration: 12 Month(s)
Documented Diagnosis Requirement: Explicitly Documented
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
Gastric Cancer:
Age Requirement: < 19
Duration: 12 Month(s)
- Quantity Limit: 100 tablets per month
- Orally administered anticancer medication.
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