- Limited Access: Must use AcariaHealth Specialty Rx.
- unspecified ST criteria Step Therapy Exists in PA
- Step Therapy: ST Multiple Generics
- Prior Authorization: Behcet's Disease:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Psoriasis (PsO):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Psoriatic Arthritis (PsA):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- I. Health Net Approved Indications and Usage Guidelines: A. Psoriatic Arthritis: 1. Diagnosis of Active Psoriatic Arthritis; AND 2. Confirmed by a Rheumatologist or Dermatologist; AND 3. Failure or clinically significant adverse effects to MTX unless contraindicated. B. Plaque Psoriasis: 1. Diagnosis of chronic moderate to severe plaque psoriasis; AND 2. Prescribed by a Dermatologist or Rheumatologist; AND 3. Failure or clinically significant adverse effects to ONE of the following therapies either alone or in combination, unless contraindicated: i. Methotrexate up to a dose of 15-20 mg/week; OR ii. If methotrexate is contraindicated, failure or clinically significant adverse effects to PUVA Therapy or UVB, or cyclosporine or acitretin. II. Authorization Limit: 6 months or to member's renewal date, whichever is longer.
- Behcet's Disease:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Dermatologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Psoriasis (PsO):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Dermatologist;Rheumatologist
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 3
Overall % of Body Surface For Initiation With Sensitive Areas: N/A
Sensitive Area BSA Percent override: No
Psoriatic Arthritis (PsA):
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Dermatologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
TB Test required: No
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