- Atopic Dermatitis (Eczema):
Age Requirement: >= 12
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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: 10
Physician Attestation for Initiation Required: No
Step Trial Length Period: Variable
Reauthorization Assessment Required: None
Psoriatic Arthritis (PsA):
Age Requirement: >= 18
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: = 6 month(s)
TB Test required: No
Rheumatoid Arthritis (RA):
Age Requirement: >= 18
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
- Prior Authorization: Atopic Dermatitis (Eczema):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 1 plan year
Reauthorization Required: Yes
Psoriatic Arthritis (PsA):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- Step Therapy: Atopic Dermatitis (Eczema), Rheumatoid Arthritis (RA):
ST Multiple Generics
Psoriatic Arthritis (PsA):
ST Single Brand
- Must use AcariaHealth Specialty Rx.
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