- -Must use AcariaHealth Specialty Rx
- Step Therapy: Hidradenitis Suppurativa (HS), Uveitis:
ST Multiple Generics
Psoriasis (PsO): ST Single Generic
- Prior Authorization: Hidradenitis Suppurativa (HS):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
Psoriasis (PsO): Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Uveitis: Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
- Hidradenitis Suppurativa (HS):
Age Requirement: >= 12
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Dermatologist;Gastroenterologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Psoriasis (PsO): 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
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 3
Overall % of Body Surface For Initiation With Sensitive Areas: Unspecified
Psoriasis Classification: Moderate-Severe
Sensitive Area BSA Percent override: No
Uveitis: Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Ophthalmologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
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