- Aggressive Systemic Mastocytosis (ASM), Gastrointestinal Stromal Tumor:
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: = 1 plan year
Chronic Myelogenous Leukemia: 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)
- Anti-Cancer:Maximum $200 copayment per State Law.
- Prior Authorization: Aggressive Systemic Mastocytosis (ASM), Gastrointestinal Stromal Tumor:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Chronic Myelogenous Leukemia: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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