- Prior Authorization: Acute Lymphoblastic Leukemia, Chronic Lymphocytic Leukemia, Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Graft Versus Host Disease (GVHD), Marginal Zone Lymphoma, Waldenstrom Macroglobulinemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Granulomatosis with Polyangiitis, Microscopic Polyangiitis (MPA):
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 Month(s)
Multiple Sclerosis (MS):
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Myasthenia Gravis, Non Hodgkin Lymphoma (NHL), Uveitis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Pemphigus Vulgaris, Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 5 EA PER 30 day(s)
- Quantity Limit: 2 tablets per 1 day(s).
- Step Therapy: Overactive Bladder:
ST Multiple Generics
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