- Asthma (injectable):
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
# of exacerbations in prior year: >= 2
History of corticosteroid use: >= 3 months
Additional controller failure requirement: 1
EOS levels required at baseline (cellsmcl): >= 150
Diagnosis Type: Moderate to Severe
Evidence of Asthma Indicators: 2 of FEV1 <= 80% predicted;FEV1 reversibility of >= 12% and 200ml after rescue
Patient Weight Required: No
Must Be Compliant with Therapy: No
Non-smoker or Will Begin Smoking Cessation Efforts: No
Symptoms Are Not Adequately Controlled: Yes
Exacerbation Requiring Treatment with Systemic Corticosteroid: Optional
Use in Combination with Other Injectable Asthma Product: No
Positive Skin Test or In Vitro Test (RAST) to a Perennial Aeroallergen: No
IgE Level Required: No
Administered in a Controlled Healthcare Setting with Access to Emergency Medications: No
Submission of Medical Records Required: No
Eosinophilic asthma phenotype: Yes
Injectable ST Required: No
Asthma OCS Dependent:
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Atopic Dermatitis (Eczema):
Age Requirement: >= 1
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
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: Variable
Reauthorization Assessment Required: None
Eosinophilic Esophagitis (EoE):
Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Nasal Polyposis:
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
- PA Applies
- Step Therapy: Asthma (injectable), Asthma OCS Dependent, Nasal Polyposis:
ST Multiple Generics
Atopic Dermatitis (Eczema), Eosinophilic Esophagitis (EoE):
ST Single Generic
- Prior Authorization: Asthma (injectable):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 1 year(s)
Reauthorization Required: Yes
Asthma OCS Dependent:
Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 1 year(s)
Reauthorization Required: Yes
Atopic Dermatitis (Eczema):
Documented Diagnosis: Yes
Age Requirement: >= 1
Duration: 1 year(s)
Reauthorization Required: Yes
Eosinophilic Esophagitis (EoE):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 1 year(s)
Reauthorization Required: Yes
Nasal Polyposis:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
- 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; Quantity Limits apply:
11 years of age or younger: 1 syringe/pen every 28 days
12 years of age or older: 2 syringes/pens every 28 days
For details on drug coverage click HERE;
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