- Quantity Limit: (180 tabs / 30
days)
- Prior Authorization: Adult Onset Stills Disease (AOSD):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Cryopyrin-Associated Periodic Syndromes (CAPS):
Age Requirement: >= 4
Duration: 6 Month(s)
Reauthorization Required: Yes
Gouty Arthritis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Juvenile Idiopathic Arthritis:
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
Periodic Fever Syndromes:
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
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;- Quantity Limit: 365 ea per fill retail,365 ea per fill mail
|