- Epithelioid Sarcoma:
Age Requirement: >= 16
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Follicular Lymphoma (FL): Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Prior Authorization: Epithelioid Sarcoma:
Documented Diagnosis: Yes
Age Requirement: >= 16
Duration: 1 plan year
Reauthorization Required: Yes
Follicular Lymphoma (FL): Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
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