- Quantity Limits Apply
- Prior Authorization: Granulomatosis with Polyangiitis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Microscopic Polyangiitis (MPA):
Duration: 6 Month(s)
Reauthorization Required: Yes
- Granulomatosis with Polyangiitis:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Microscopic Polyangiitis (MPA):
Duration: 6 Month(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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