- Prior Authorization: Asthma (injectable):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 1 year(s)
Reauthorization Required: Yes
Asthma OCS Dependent: Documented Diagnosis: Yes
Age Requirement: >= 6
Duration: 1 year(s)
Reauthorization Required: Yes
Atopic Dermatitis (Eczema): Documented Diagnosis: Yes
Age Requirement: >= 1
Duration: 1 year(s)
Reauthorization Required: Yes
Eosinophilic Esophagitis (EoE): Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 1 year(s)
Reauthorization Required: Yes
Nasal Polyposis: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
- Quantity Limit: 28 tablets per 30 day(s).
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