- Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA):
Duration: 12 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
Atopic Dermatitis (Eczema):
Age Requirement: >= 12
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Dermatologist;Immunologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Initial Authorization - POEM Values: N/A
Initial Authorization - SCORAD Values: N/A
Initial Authorization - EASI Values: N/A
Initial Authorization - IGA Values: N/A
Initial Authorization - PGA Values: N/A
Initial Authorization - ISGA Values: N/A
Initial Authorization - BSA Values: N/A
Physician Attestation for Initiation Required: No
Step Trial Length Period: Variable
Psoriatic Arthritis (PsA):
Duration: 12 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
Ulcerative Colitis (UC):
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
- Step Therapy: ST Generic and Brand
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Prior Authorization: Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Atopic Dermatitis (Eczema):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 12 Month(s)
Reauthorization Required: Yes
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