- Step Therapy: Ankylosing Spondylitis (AS), Psoriasis (PsO):
ST Generic and Brand
Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA):
ST Multiple Generics
- Prior Authorization: Ankylosing Spondylitis (AS), Psoriasis (PsO), Psoriatic Arthritis (PsA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Crohn's Disease (CD), Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 1 year(s)
Reauthorization Required: Yes
Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
Uveitis:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: Yes
Crohn's Disease (CD), Ulcerative Colitis (UC):
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
Psoriasis (PsO):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: Yes
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 3
Overall % of Body Surface For Initiation With Sensitive Areas: N/A
Sensitive Area BSA Percent override: No
Rheumatoid Arthritis (RA):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
Uveitis:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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