- Step Therapy: ST Multiple Generics
- Quantity Limit: 1 tablets 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;
- Ankylosing Spondylitis (AS), Ulcerative Colitis (UC):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: No
Atopic Dermatitis (Eczema):
Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
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
- Prior Authorization: Ankylosing Spondylitis (AS), Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
Reauthorization Required: Yes
Atopic Dermatitis (Eczema):
Documented Diagnosis: Yes
Age Requirement: >= 12
Duration: 1 year(s)
Reauthorization Required: Yes
- PA Applies
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