- Quantity Limits Apply
- Prior Authorization: Asthma (injectable), Nasal Polyposis:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
EGPA: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: Asthma (injectable):
ST Multiple Generics
Nasal Polyposis: ST Single Generic
- Asthma (injectable):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Allergist;Immunologist;Pulmonologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12
# of exacerbations in prior year: not specified
History of corticosteroid use: <= 12 months
Additional controller failure requirement: 1
EOS levels required at baseline (cellsmcl): >= 150
Diagnosis Type: Severe
Evidence of Asthma Indicators: 1 of Baseline Asthma Control Questionnaire-7 (ACQ-7) score;Baseline Asthma Control Test (ACT) score;FEV1 < 80% predicted
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: Yes
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: Yes
Exclusion Condition(s): 1 of Acute bronchospasm;Status asthmaticus
Eosinophilic asthma phenotype: Yes
Injectable ST Required: No
EGPA: Duration: 12 Month(s)
Specialist Required: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Immunologist;Pulmonologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Covered by Exception: No
Dose Requirement: N/A
Documented Diagnosis: Yes
Nasal Polyposis: Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Allergist;Immunologist;Otolaryngologist (Ear, Nose, and Throat Specialist);Pulmonologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
|