- Step Therapy: Nephrotic Syndrome:
ST Generic and Brand
- Prior Authorization: Adjunctive Rheumatoid Arthritis:
Documented Diagnosis: Yes
Infantile Spasm:
Documented Diagnosis: Yes
Age Requirement: < 2
Duration: 3 Month(s)
Reauthorization Required: Yes
Multiple Sclerosis Exacerbation:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 3 week(s)
Nephrotic Syndrome:
Documented Diagnosis: Yes
Age Requirement: > 2
Duration: 3 Month(s)
Reauthorization Required: Yes
- Adjunctive Rheumatoid Arthritis:
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Infantile Spasm:
Age Requirement: < 2
Duration: 3 Month(s)
Specialist Required: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 3 month(s)
Treatment for Age <2 years old: Yes
Diagnosis Types: infantile spasms (West syndrome)
Supporting Documentation Requirements: Chart Notes
Reauthorization Requirement(s): Positive response to therapy
Documented Diagnosis: Yes
Multiple Sclerosis Exacerbation:
Age Requirement: >= 18
Duration: 3 week(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: No
Duration of Reauthorization: N/A
Nephrotic Syndrome:
Age Requirement: > 2
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Nephrologist
Reauthorization Required: Yes
Duration of Reauthorization: = 3 month(s)
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