- Anti-Cancer: Maximum $200 copayment per State Law.
- Prior Authorization: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Aggressive Systemic Mastocytosis (ASM):
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Immunologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Gastrointestinal Stromal Tumor:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Step Therapy: Aggressive Systemic Mastocytosis (ASM):
ST Multiple Generics
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