- 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: = 1 year(s)
# of exacerbations in prior year: >= 1
History of corticosteroid use: >= 3 months
Additional controller failure requirement: >= 1
EOS levels required at baseline (cellsmcl): >= 150
Diagnosis Type: Moderate to Severe
Evidence of Asthma Indicators: 1 of FEV1 <= 80% predicted;FEV1/FVC < 0.80
Patient Weight Required: No
Must Be Compliant with Therapy: No
Non-smoker or Will Begin Smoking Cessation Efforts: No
Symptoms Are Not Adequately Controlled: Yes
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: No
Eosinophilic asthma phenotype: Yes
Injectable ST Required: No
Asthma OCS Dependent:
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: = 1 year(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: = 1 year(s)
- Quantity Limit: limit maximum 15 EA PER 30 day(s)
- Prior authorization required. Member should try alternative(s) before submitting a prior authorization. If approved, covered at appropriate tier under the member's pharmacy benefit.
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