- Prior Authorization: Juvenile Idiopathic Arthritis:
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 1 plan year
Reauthorization Required: Yes
Psoriasis (PsO):
Documented Diagnosis: Yes
Duration: 1 plan year
Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
- Step Therapy: ST Single Generic
- Juvenile Idiopathic Arthritis:
Age Requirement: >= 2
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
TB Test required: No
Psoriasis (PsO):
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
Psoriasis Classification: severe
Sensitive Area BSA Percent override: No
Rheumatoid Arthritis (RA):
Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
TB Test required: No
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