- Quantity Limit: 2 tablets per 1 day(s).
- Prior Authorization: Ankylosing Spondylitis (AS):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
Juvenile Idiopathic Arthritis:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 2
Duration: 1 year(s)
Reauthorization Required: Yes
Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Duration: 1 year(s)
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- PA Applies
- Step Therapy: Ankylosing Spondylitis (AS), Juvenile Idiopathic Arthritis:
ST Multiple Brands
Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
ST Multiple Generics
- Ankylosing Spondylitis (AS):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
Juvenile Idiopathic Arthritis:
Age Requirement: >= 2
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
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