- Step Therapy: Psoriasis (PsO):
ST Multiple Generics
- Derm: Acne Vulgaris:
Age Requirement: >= 9
Duration: 3 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Limited to non-cosmetic use: No
Supporting Documentation Requirements: Chart Notes
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- May be covered under Medical Benefit.
|