- Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
- Melanoma (MEL):
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
NSCLC with BRAF Mutation:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Step Therapy: NSCLC with BRAF Mutation:
ST Single Brand
- Prior Authorization: Melanoma (MEL):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
NSCLC with BRAF Mutation:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
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