- High strength requires PA for members age 65 and older;
- Prior Authorization: Crohn's Disease (CD):
Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 6 Month(s)
Reauthorization Required: Yes
Hidradenitis Suppurativa (HS):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 5
Duration: 1 plan year
Reauthorization Required: Yes
- Quantity Limit: limit maximum 1 ML PER 30 day(s)
- Non-Metastatic Prostate Cancer:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist;Urologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
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