- Prior Authorization: Colorectal Cancer:
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
Esophageal Cancer, Head and Neck Cancer, Hodgkin Lymphoma (HL), Kidney Cancer, Malignant Pleural Mesothelioma, Melanoma (MEL), Merkel Cell Carcinoma, Small Cell Lung Cancer, Uveal Melanoma: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Gastric Cancer: Age Requirement: >= 18
Duration: 6 Month(s)
Hepatocellular Carcinoma: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
NSCLC EGFR Mutated, NSCLC Systemic Therapy: Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Tumor Mutational Burden-High (TMB-H) Cancer: Duration: 6 Month(s)
Reauthorization Required: Yes
Urothelial/Bladder Cancer: Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Diabetes Type 2: GLP1 + Combo:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Supporting Documentation Requirements: Medication History
- Quantity Limit: limit maximum 15 EA PER 30 day(s)
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