- Crohn's Disease (CD):
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
Hidradenitis Suppurativa (HS): Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Ulcerative Colitis (UC): Age Requirement: >= 5
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
- Prior Authorization: Diabetic Medical Supplies:
Duration: 1 year(s)
- Quantity Limit: 200 needles per 30 day(s).
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