- Ankylosing Spondylitis (AS):
Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
Psoriasis (PsO):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: N/A
Overall % of Body Surface For Initiation With Sensitive Areas: N/A
Sensitive Area BSA Percent override: No
Psoriatic Arthritis (PsA):
Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: Yes
- Quantity Limit: 2 syringes per 28 day(s).
- Prior Authorization: Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA):
Age Requirement: >= 18
Duration: 12 Month(s)
Psoriasis (PsO):
Documented Diagnosis: Yes
Duration: 1 year(s)
- PA Applies
- Step Therapy: Psoriasis (PsO):
ST Multiple Generics
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
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