- Amyotrophic Lateral Sclerosis (ALS):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Asthma (injectable):
Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
# of exacerbations in prior year: >= 2
History of corticosteroid use: >= 3 months
Additional controller failure requirement: 1
EOS levels required at baseline (cellsmcl): >= 150
Diagnosis Type: Moderate to Severe
Evidence of Asthma Indicators: 2 of FEV1 <= 80% predicted;FEV1 reversibility of >= 12% and 200ml after rescue
Patient Weight Required: No
Must Be Compliant with Therapy: No
Non-smoker or Will Begin Smoking Cessation Efforts: No
Symptoms Are Not Adequately Controlled: Yes
Exacerbation Requiring Treatment with Systemic Corticosteroid: Optional
Use in Combination with Other Injectable Asthma Product: No
Positive Skin Test or In Vitro Test (RAST) to a Perennial Aeroallergen: No
IgE Level Required: No
Administered in a Controlled Healthcare Setting with Access to Emergency Medications: No
Submission of Medical Records Required: No
Eosinophilic asthma phenotype: Yes
Injectable ST Required: No
Asthma OCS Dependent: Age Requirement: >= 6
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Atopic Dermatitis (Eczema): Age Requirement: >= 1
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Initial Authorization - POEM Values: N/A
Initial Authorization - SCORAD Values: N/A
Initial Authorization - EASI Values: N/A
Initial Authorization - IGA Values: N/A
Initial Authorization - PGA Values: N/A
Initial Authorization - ISGA Values: N/A
Initial Authorization - BSA Values: N/A
Physician Attestation for Initiation Required: No
Step Trial Length Period: Variable
Reauthorization Assessment Required: None
Eosinophilic Esophagitis (EoE): Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Nasal Polyposis: Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
- PA_APPLIES
- PA_APPLIES
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