- Prior Authorization: Asthma (injectable), Asthma OCS Dependent:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 6 Month(s)
Reauthorization Required: Yes
Atopic Dermatitis (Eczema): Documented Diagnosis: Yes
Age Requirement: >= 1
Duration: 6 Month(s)
Reauthorization Required: Yes
Eosinophilic Esophagitis (EoE): Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
Nasal Polyposis: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- 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
- Prior Authorization: PA Applies
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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