- Parkinson's Disease:
Duration: 1 year(s)
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Clinically documented acute, intermittent treatment of hypomobility "off" episodes: No
Concomitant Use of Max Tolerable Dose of levodopa + 1 selegiline,pramipexole,entacapone,rasagiline: No
Use as adjunct therapy: No
Requires concomitant anti-emetic agent: No
- Prior Authorization: Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
Juvenile Idiopathic Arthritis:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 2
Duration: 1 year(s)
Reauthorization Required: Yes
Psoriasis (PsO):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 4
Duration: 1 year(s)
- Step Therapy: Derm: Acne Vulgaris:
ST Single Generic
- Prior Authorization: PA Required
- Quantity Limit: limit maximum 30 day(s) supply
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