- Available only through Specialty Pharmacy;
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;
- Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
Juvenile Idiopathic Arthritis: Age Requirement: >= 2
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
Psoriasis (PsO): Age Requirement: >= 4
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: Yes
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 3
Overall % of Body Surface For Initiation With Sensitive Areas: 3
Psoriasis Classification: chronic, moderate to severe
Sensitive Area BSA Percent override: No
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