- PA_APPLIES
- May be covered under Medical Benefit.
- Asthma (injectable):
Age Requirement: >= 6
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Allergist;Immunologist;Pulmonologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
# of exacerbations in prior year: >= 2
History of corticosteroid use: <= 12 months
Additional controller failure requirement: 1
EOS levels required at baseline (cellsmcl): >= 150
Diagnosis Type: Severe
Patient Weight Required: No
Must Be Compliant with Therapy: No
Non-smoker or Will Begin Smoking Cessation Efforts: No
Symptoms Are Not Adequately Controlled: No
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: Yes
Exclusion Condition(s): 1 of Acute bronchospasm;Status asthmaticus
Eosinophilic asthma phenotype: Yes
Injectable ST Required: No
EGPA:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Immunologist;Nephrologist;Pulmonologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Covered by Exception: No
Dose Requirement: <= 300 mg
Exclusion Condition(s): 1 of Acute bronchospasm;All Non-FDA Approved Indications;Status asthmaticus
Documented Diagnosis: Yes
Nasal Polyposis:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Immunologist;Otolaryngologist (Ear, Nose, and Throat Specialist)
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
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