- Pulmonary Arterial Hypertension:
Duration: 6 Month(s)
Specialist Required: Yes
- Step Therapy: Post-herpetic Neuralgia:
ST Multiple Generics
- Age Limit: This drug may require prior authorization if your age does not fall within manufacturer, FDA, or clinical recommendations.
Up to 6 yrs old
- Growth Hormone Deficiency:
Duration: 6 Month(s)
Specialist Required: Yes
Specialist Type(s): 1 of Endocrinologist;Pediatric Endocrinologist
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
Pediatric Growth Hormone Deficiency (GHD) Requirement(s): 3 of Diagnosis of Pediatric Growth Hormone Deficiency;Epiphyses is Open;Growth Velocity Required;Height Standard Deviation Score Required;History of Neonatal Hypoglycemia Required;Insulin Growth Factor Binding Protein-3 (IGFBP-3) Level Required;Insulin-like Growth Factor 1 (IGF-1/Somatomedin-C) Level Required
Pediatric - GH Stimulation Test: = 2
Pediatric - Pituitary Hormone Deficiency: >= 1
Pediatric - Reauthorization Requirement(s): 2 of Increase in growth rate;Positive response to therapy
Adult Growth Hormone Deficiency Requirement(s): 3 of Cannot be used for athletic performance enhancement;Diagnosis of Adult-onset Growth Hormone Deficiency (GHD);Diagnosis of Childhood-onset Growth Hormone Deficiency (GHD);Insulin-like Growth Factor 1 (IGF-1/Somatomedin-C) Level Required
Adult - GHD Stimulation Test: >= 1
Adult - Pituitary Hormone Deficiency: >= 3
Adult - Duration of Initial Authorization: >= 6 month(s)
Adult - Reauthorization Requirement(s): 3 of Cannot be used for athletic performance enhancement;Insulin-like Growth Factor 1 (IGF-1) Required;Positive response to therapy
Adult - Duration of Reauthorization: >= 6 month(s)
Documented Diagnosis of Other Approved Indications: 1 of AIDs/HIV Associated Wasting or Cachexia;Chronic Renal Insufficiency;Growth Failure in Children Born Small for Gestational Age (SGA);Idiopathic Short Stature (ISS);Noonan Syndrome;Prader-Willi Syndrome in Children (PWS);Short Bowel Syndrome (SBS);Short Stature Homeobox-Containing Gene (SHOX);Turner's Syndrome (TS)
Documented Diagnosis: Yes
HIV Wasting: Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: No
Medical Test Required: No
Specialist Type(s): HIV Specialist
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
- Available only through Specialty Pharmacy;
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; Dosing Limit: 15 mg/kg once per month for up to 5 doses per RSV season;
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