- ST_APPLIES
- 1;
- Step Therapy: Tumor Mutational Burden-High (TMB-H) Cancer:
ST Single Brand
Urothelial/Bladder Cancer:
ST Single Generic
- Prior Authorization: Crohn's Disease (CD):
Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 6 Month(s)
Reauthorization Required: Yes
Hidradenitis Suppurativa (HS):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 5
Duration: 1 plan year
Reauthorization Required: Yes
- ST_APPLIES
- Prior Authorization: PA_APPLIES
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