Sharp Health Plan - All plan years
Xhance (fluticasone propionate)
Drugs for the Nose : Allergy
  • Ankylosing Spondylitis (AS):
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

    Crohn's Disease (CD):
    Age Requirement: >= 6
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Gastroenterologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

    Psoriasis (PsO):
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Dermatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No
    History of Plaque Psoriasis: N/A
    Overall % of Body Surface For Initiation: 3
    Overall % of Body Surface For Initiation With Sensitive Areas: 3
    Psoriasis Classification: severe
    Sensitive Area BSA Percent override: No

    Psoriatic Arthritis (PsA):
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Dermatologist;Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

    Rheumatoid Arthritis (RA):
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

    Ulcerative Colitis (UC):
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Gastroenterologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

  • Derm: Acne Vulgaris:
    Duration: 12 Month(s)
    Documented Diagnosis: No
    Medical Test Required: No
    Reauthorization Required: No
    Limited to non-cosmetic use: No

    Topical Psoriasis:
    Duration: 12 Month(s)
    Medical Test Required: No
    Reauthorization Required: No
    Documented Diagnosis: No

  • Step Therapy: ST_APPLIES
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