- Step Therapy: ST Multiple Generics
- Atopic Dermatitis (Eczema):
Age Requirement: >= 12
Duration: 1 year(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Initial Authorization - POEM Values: N/A
Initial Authorization - SCORAD Values: N/A
Initial Authorization - EASI Values: N/A
Initial Authorization - IGA Values: 3
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: 1 month(s)
Reauthorization Assessment Required: IGA
Ulcerative Colitis (UC):
Duration: 1 year(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Gastroenterologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
TB Test required: No
- Prior Authorization: Atopic Dermatitis (Eczema):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 12
Duration: 1 year(s)
Reauthorization Required: Yes
Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Duration: 1 year(s)
Reauthorization Required: Yes
- Available through Specialty Pharmacy;
- PA Required
- Quantity Limit: 30 day supply per 1 fill(s).
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