- Step Therapy: Asthma (injectable), Asthma OCS Dependent, Atopic Dermatitis (Eczema):
ST Multiple Generics
Eosinophilic Esophagitis (EoE): ST Single Generic
Nasal Polyposis: ST Generic and Brand
- Prior Authorization: Asthma (injectable), Asthma OCS Dependent:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 6
Duration: 6 Month(s)
Reauthorization Required: Yes
Atopic Dermatitis (Eczema): Documented Diagnosis: Yes
Age Requirement: >= 1
Duration: 6 Month(s)
Reauthorization Required: Yes
Eosinophilic Esophagitis (EoE): Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 12
Duration: 6 Month(s)
Reauthorization Required: Yes
Nasal Polyposis: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Asthma (injectable):
Age Requirement: >= 6
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Allergist;Immunologist;Pulmonologist
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
# of exacerbations in prior year: >= 2
History of corticosteroid use: not specified
Additional controller failure requirement: 1
EOS levels required at baseline (cellsmcl): >= 150
Diagnosis Type: Unspecified
Patient Weight Required: No
Must Be Compliant with Therapy: No
Non-smoker or Will Begin Smoking Cessation Efforts: No
Symptoms Are Not Adequately Controlled: Yes
Exacerbation Requiring Treatment with Systemic Corticosteroid: Optional
Use in Combination with Other Injectable Asthma Product: No
Positive Skin Test or In Vitro Test (RAST) to a Perennial Aeroallergen: No
IgE Level Required: No
Administered in a Controlled Healthcare Setting with Access to Emergency Medications: No
Submission of Medical Records Required: Yes
Exclusion Condition(s): 1 of Acute bronchospasm;Status asthmaticus
Eosinophilic asthma phenotype: Yes
Injectable ST Required: No
Asthma OCS Dependent: Age Requirement: >= 6
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Allergist;Immunologist;Pulmonologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Atopic Dermatitis (Eczema): Age Requirement: >= 1
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 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: 10
Physician Attestation for Initiation Required: No
Step Trial Length Period: Variable
Reauthorization Assessment Required: BSA
Eosinophilic Esophagitis (EoE): Age Requirement: >= 12
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Allergist;Gastroenterologist;Immunologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Nasal Polyposis: Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Immunologist;Otolaryngologist (Ear, Nose, and Throat Specialist)
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
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