- Prior Authorization: Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Reauthorization Required: Yes
Juvenile Idiopathic Arthritis: Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 2
Duration: 1 year(s)
Reauthorization Required: Yes
Psoriasis (PsO): Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 4
Duration: 1 year(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 48 EA PER 25 day(s)
- Central Precocious Puberty:
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Onset of Secondary Sexual Characteristics for Females: < 8 year(s)
Onset of Secondary Sexual Characteristics for Males: < 9 year(s)
Documented Diagnosis: Yes
- Subject to initial 7-day limit, if age 19 or younger, subject to initial 3-day limit
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