- Quantity Limit: limit maximum 182 EA PER fill retail
- Small Cell Lung Cancer:
Age Requirement: <= 19
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
ECOG Score Requirement Included in Policy: N/A
Diagnosis Types: 2 of Relapse within 6 mos of initial therapy following a complete or partial response;Small Cell Lung Cancer
- Prior Authorization: Small Cell Lung Cancer:
Documented Diagnosis: Yes
Age Requirement: <= 19
Duration: 12 Month(s)
Reauthorization Required: Yes
- Orally administered anticancer medication.
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