
Covered Uses: | All FDA-approved indications not otherwise excluded from Part D. |
Exclusion Criteria: | |
Required Medical Information: | Patient has experienced severe thrombocytopenia (e.g., platelet count less than equal to 20,000/mcL) from previous chemotherapy OR for patient is considered to be at high risk for the development of severe thrombocytopenia. |
Age Restrictions: | |
Prescriber Restrictions: | |
Coverage Duration: | 12 months |
Other Criteria: | |
Excluded Drug Criteria: |