- Quantity Limit: limit maximum 1 ML PER 30 day(s)
- Uveitis:
Age Requirement: >= 12
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Ophthalmologist
Reauthorization Required: Yes
Duration of Reauthorization: = 3 month(s)
- Hidradenitis Suppurativa (HS):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 24 month(s)
Psoriasis (PsO):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 24 month(s)
TB Test required: No
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: N/A
Overall % of Body Surface For Initiation With Sensitive Areas: N/A
Psoriasis Classification: Moderate-Severe
Sensitive Area BSA Percent override: No
Uveitis:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): 1 of AllCare Plus Pharmacy;BriovaRx
Reauthorization Required: No
Duration of Reauthorization: N/A
- May process through Pharmacy or Medical benefit depending on Patient location;
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