| Oscar Health - 2018 to Present |
| Xylon (hydrocodone-ibuprofen) |
| Drugs for Pain and Fever : Arthritis and Pain Drugs |
- Lupus Nephritis:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Nephrologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Systemic Lupus Erythematosus (SLE):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Positive Autoantibody Test Required: Unspecified
SELENA-SLEDAI Score Required: N/A
Reauthorization SELENA-SLEDAI Score Required: N/A
Reauthorization Requirements Documented in Policy: 3 of Adherence to product and standard of care therapy;Meet Initial Criteria;Shows positive clinical response
Does Policy Include Excluded Indications: No
Supporting Documentation Requirements: 1 of Chart Notes;Medical Tests
- Step Therapy: ST Single Generic
- Quantity Limit: 56 day supply per 1 fill(s).
- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
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