- Quantity Limit: limit maximum 3 EA PER 28 day(s)
- Asthma (injectable):
Age Requirement: >= 6
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
# of exacerbations in prior year: not specified
Additional controller failure requirement: 1
EOS levels required at baseline (cellsmcl): >= 150
Diagnosis Type: Unspecified
Patient Weight Required: No
Must Be Compliant with Therapy: No
Non-smoker or Will Begin Smoking Cessation Efforts: Yes
Symptoms Are Not Adequately Controlled: Yes
Exacerbation Requiring Treatment with Systemic Corticosteroid: Optional
Use in Combination with Other Injectable Asthma Product: No
Positive Skin Test or In Vitro Test (RAST) to a Perennial Aeroallergen: No
IgE Level Required: No
Administered in a Controlled Healthcare Setting with Access to Emergency Medications: No
Submission of Medical Records Required: Yes
Exclusion Condition(s): 1 of Acute bronchospasm;Other;Status asthmaticus
Eosinophilic asthma phenotype: Yes
Injectable ST Required: No
EGPA:
Age Requirement: >= 18
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Covered by Exception: No
Dose Requirement: N/A
Exclusion Condition(s): All Other Indications
Documented Diagnosis: Yes
Nasal Polyposis:
Age Requirement: >= 18
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Prior Authorization: Asthma (injectable):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 6 Month(s)
Reauthorization Required: Yes
EGPA:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Nasal Polyposis:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Step Therapy: EGPA:
ST Single Generic
Nasal Polyposis:
ST Multiple Generics
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