Health Net
Piqray (200 MG Daily Dose) (alpelisib)
Drugs for Cancer : Drugs for Cancer
  • Quantity Limit: limit maximum 3 EA PER fill retail
  • Prior Authorization: Anemia:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Anemia due to Chemotherapy:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 5
    Duration: 6 Month(s)
    Reauthorization Required: Yes

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