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PHARMACY COVERAGE GUIDELINES SECTION: DRUGSORIGINAL EFFECTIVE DATE: LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:1/22/15 1/18/18 1/18/18GLEEVEC (desolate) oral tablet DESOLATE oral

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6. Clearly indicate the purpose for filling out the form and the specific medical services or medications related to Mesylate treatment.
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