- Behcet's Disease:
Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Psoriasis (PsO):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: N/A
Overall % of Body Surface For Initiation With Sensitive Areas: N/A
Psoriasis Classification: Moderate-Severe
Sensitive Area BSA Percent override: No
Psoriatic Arthritis (PsA):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Prior Authorization: Behcet's Disease:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Psoriasis (PsO), Psoriatic Arthritis (PsA):
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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