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Dactinomycin - Dactinomycin injection, Powder, Lyophilized, For Solution
The Health Plan (of the Upper Ohio Valley)
The Health Plan (of the Upper Ohio Valley) Coverage for Dactinomycin - Dactinomycin injection, Powder, Lyophilized, For Solution
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5
Commercial
3
Managed Medicaid
1
Medicare
1
Commercial
Commercial - HMO
PA Required
No Step Therapy
No Quantity Limit
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Commercial - PPO
PA Required
No Step Therapy
No Quantity Limit
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Commercial - Point of Service
PA Required
No Step Therapy
No Quantity Limit
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Managed Medicaid
Managed Medicaid - HMO - Medicaid
No PA
No Step Therapy
No Quantity Limit
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Medicare
Medicare - Medicare Advantage Part D
PA Required
No Step Therapy
No Quantity Limit
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