- Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Orally administered anticancer medication.
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
- Step Therapy: Marginal Zone Lymphoma:
ST Single Brand
- Prior Authorization: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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