- QL (150 per Rx);
- Prior Authorization: Ankylosing Spondylitis (AS), Psoriasis (PsO), Psoriatic Arthritis (PsA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Crohn's Disease (CD), Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 1 year(s)
Reauthorization Required: Yes
Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
Uveitis:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Step Therapy: Diabetic Medical Supplies:
ST Multiple Brands
- Prior Authorization: PA Required
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