- Quantity Limits Apply
- Graft Versus Host Disease (GVHD):
Age Requirement: >= 12
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Bone Marrow Specialist;Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Myelofibrosis:
Age Requirement: >= 18
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Polycythemia Vera (PV):
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Anti-Cancer:Maximum $200 copayment per State Law.
- Step Therapy: Graft Versus Host Disease (GVHD):
ST Single Generic
- Prior Authorization: Graft Versus Host Disease (GVHD):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 12 Month(s)
Reauthorization Required: Yes
Myelofibrosis:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Polycythemia Vera (PV):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
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