- Prior Authorization: Atopic Dermatitis (Eczema):
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 12 Month(s)
Reauthorization Required: Yes
- Atopic Dermatitis (Eczema):
Age Requirement: >= 2
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Initial Authorization - POEM Values: N/A
Initial Authorization - SCORAD Values: N/A
Initial Authorization - EASI Values: N/A
Initial Authorization - IGA Values: N/A
Initial Authorization - PGA Values: N/A
Initial Authorization - ISGA Values: N/A
Initial Authorization - BSA Values: N/A
Physician Attestation for Initiation Required: No
Step Trial Length Period: N/A
Reauthorization Assessment Required: None
- Step Therapy: Atopic Dermatitis (Eczema):
ST Multiple Generics
- Quantity Limit: limit maximum 60 GM PER fill retail
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