- Prior Authorization: Ankylosing Spondylitis (AS), Crohn's Disease (CD), Nonradiographic Axial Spondyloarthritis, Psoriasis (PsO):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Psoriatic Arthritis (PsA):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 1 EA PER 28 day(s)
- Glaucoma:
Age Requirement: >= 17
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Supporting Documentation Requirements: Chart Notes
Documented Diagnosis: Yes
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