- Atopic Dermatitis (Eczema):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Dermatologist;Immunologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Initial Authorization - POEM Values: N/A
Initial Authorization - SCORAD Values: N/A
Initial Authorization - EASI Values: N/A
Initial Authorization - IGA Values: N/A
Initial Authorization - PGA Values: N/A
Initial Authorization - ISGA Values: N/A
Initial Authorization - BSA Values: N/A
Physician Attestation for Initiation Required: No
Step Trial Length Period: N/A
Eosinophilic Esophagitis (EoE):
Age Requirement: >= 12
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Gastroenterologist
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
- Step Therapy: Atopic Dermatitis (Eczema):
ST Multiple Generics
Eosinophilic Esophagitis (EoE):
ST Single Generic
- Prior Authorization: Atopic Dermatitis (Eczema):
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Eosinophilic Esophagitis (EoE):
Documented Diagnosis: Yes
Age Requirement: >= 12
Reauthorization Required: Yes
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