- PA Required
- Prior Authorization: Psoriasis (PsO):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
Reauthorization Required: Yes
- Step Therapy: Psoriasis (PsO):
ST Multiple Generics
- Available through Specialty Pharmacy;
- Quantity Limit: 30 day supply per 1 fill(s).
- Psoriasis (PsO):
Age Requirement: >= 18
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
TB Test required: No
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 10
Overall % of Body Surface For Initiation With Sensitive Areas: Unspecified
Psoriasis Classification: Moderate-Severe
Sensitive Area BSA Percent override: Yes
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