- Step Therapy: Adult Onset Stills Disease (AOSD):
ST Multiple Generics
Giant Cell Arteritis:
ST Single Generic
Juvenile Idiopathic Arthritis, Rheumatoid Arthritis (RA):
ST Multiple Brands
- Adult Onset Stills Disease (AOSD):
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Appropriate Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Giant Cell Arteritis:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Juvenile Idiopathic Arthritis:
Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
TB Test required: Yes
Rheumatoid Arthritis (RA):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
TB Test required: No
- Prior Authorization: Adult Onset Stills Disease (AOSD):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Giant Cell Arteritis:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Juvenile Idiopathic Arthritis:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
|