- Step Therapy: ST Single Generic
- Prior Authorization: Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
Juvenile Idiopathic Arthritis:
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 1 year(s)
Reauthorization Required: Yes
Psoriatic Arthritis (PsA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
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; For details on drug coverage click HERE; Dosing Limit: Adult (greater than or equal to 18 years): 2 mg/kg as frequently as every 8 weeks; Pediatric (<18 years): 80 mg/m2 as frequently as every 8 weeks;
- Ankylosing Spondylitis (AS), 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
Juvenile Idiopathic Arthritis:
Age Requirement: >= 2
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: No
Psoriatic Arthritis (PsA):
Age Requirement: >= 18
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
- PA Applies
|