- Quantity Limit: 2 tablet per 1 day(s).
- Quantity Limit: 30 day supply per 1 fill(s).
- Prior Authorization: PA_APPLIES
- Prior Authorization: Juvenile Idiopathic Arthritis:
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 1 plan year
Reauthorization Required: Yes
Psoriasis (PsO):
Documented Diagnosis: Yes
Duration: 1 plan year
Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
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