- Prior Authorization: Derm: Acne Vulgaris:
Documented Diagnosis: Yes
Age Requirement: >= 9
Duration: 12 Month(s)
Reauthorization Required: Yes
- Prior Authorization: Chorea in Huntington's Disease:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Tardive Dyskinesia (TD):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- Prior Authorization: PA Required
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