- Step Therapy: Gastro: Ulcerative Colitis:
ST Single Generic
- Prior Authorization: Gastro: Ulcerative Colitis:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- I. FDA Approved Indications: Product tablet: For the induction of remission in patients with active, mild to moderate ulcerative colitis. Product rectal foam: For the induction of remission in patients with active mild to moderate distal ulcerative colitis extending up to 40 cm from the anal verge. II. Health Net Approved Indications and Usage Guidelines: Patient has active, mild to moderate ulcerative colitis. AND; Failure or clinically significant adverse effects to a one-month course of aminosalicylates (e.g., sulfasalazine, mesalamine) III. Coverage Is Not Authorized For: Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
- Gastro: Ulcerative Colitis:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Gastroenterologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Supporting Documentation Requirements: Chart Notes
TF of 5ASA product and prednisone: No
TF of 5ASA product: No
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