- Oral Anti-Cancer drug.
- Prior Authorization: Ovarian Cancer:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Ovarian Cancer:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Drug Policy Based On: FDA Approved Indications
Diagnosis Types: 3 of epithelial ovarian, fallopian tube, or primary peritoneal cancer;maintenance treatment after a complete or partial response to platinum-based chemotherapy;Recurrent disease
- Quantity Limit: limit maximum 90 EA PER 30 day(s)
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