- Prior Authorization: Ankylosing Spondylitis (AS), Psoriasis (PsO), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Crohn's Disease (CD): Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: Ankylosing Spondylitis (AS), Psoriasis (PsO):
ST Multiple Generics
Crohn's Disease (CD), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC): ST Single Generic
- Ankylosing Spondylitis (AS):
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
Crohn's Disease (CD): Age Requirement: >= 6
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Gastroenterologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
Psoriasis (PsO): Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
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: severe
Sensitive Area BSA Percent override: No
Psoriatic Arthritis (PsA): Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Dermatologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
Rheumatoid Arthritis (RA): Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
Ulcerative Colitis (UC): Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Gastroenterologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
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