- Ulcerative Colitis (UC):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Gastroenterologist
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
- Diabetic Retinopathy, Macular Edema, Macular Edema Following Retinal Vein Occlusion (RVO), Neovascular (Wet) Age-Related Macular Degeneration (AMD):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Ophthalmologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Myopic Choroidal Neovascularization (mCNV): Age Requirement: >= 18
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Ophthalmologist
Reauthorization Required: Yes
Duration of Reauthorization: = 3 month(s)
- Prior Authorization: Narcolepsy Type 1, Narcolepsy Type 2:
Documented Diagnosis: Yes
Duration: 1 year(s)
Neurology: Narcolepsy: PA Applies
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
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