- Lupus Nephritis:
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Systemic Lupus Erythematosus (SLE): Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
SELENA-SLEDAI Score Required: N/A
Reauthorization SELENA-SLEDAI Score Required: N/A
Does Policy Include Excluded Indications: No
- Prior Authorization: Reduction of CV events in CAD/PAD:
Duration: 1 year(s)
- Quantity Limit: limit maximum 21 EA PER 28 day(s)
- Quantity Limit: limit maximum 1,575 ML PER 28 day(s)
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