- 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
Additional controller failure requirement: 1
Diagnosis Type: Moderate to Severe
Evidence of Asthma Indicators: Pre-treatment serum IgE (IU/mL) >= 30 in age >= 6
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: Yes
IgE Level Required: Yes
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: No
Injectable ST Required: No
Chronic Idiopathic Urticaria (CIU): Age Requirement: >= 12
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Dermatologist;Immunologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
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: = 12 month(s)
- Step Therapy: Chronic Idiopathic Urticaria (CIU):
ST Multiple Generics
Nasal Polyposis: ST Generic and Brand
- Prior Authorization: Asthma (injectable):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 6 Month(s)
Reauthorization Required: Yes
Chronic Idiopathic Urticaria (CIU): Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
Nasal Polyposis: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
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