- Colorectal Cancer:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis Requirement: Explicitly Documented
Medical Test Required: Yes
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Documented Diagnosis: Yes
Specialty Pharmacy is Required: Not Defined
Gastric Cancer: Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
- Anti-Cancer:Maximum $200 copayment per State Law.
- Prior Authorization: Colorectal Cancer:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Gastric Cancer: Age Requirement: >= 18
Duration: 1 plan year
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