Health Net
Follistim AQ (follitropin beta)
Hormones : Drugs for Women
  • PA_APPLIES
  • Lupus Nephritis:
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Nephrologist;Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Systemic Lupus Erythematosus (SLE):
    Age Requirement: >= 5
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Positive Autoantibody Test Required: Unspecified
    SELENA-SLEDAI Score Required: N/A
    Reauthorization SELENA-SLEDAI Score Required: N/A
    Patient Exclusion Criteria Documented in Policy: 1 of Excluded for patients receiving intravenous cyclophosphamide (Cytoxan);Excluded for patients receiving other biologic therapies;Excluded for patients with HIV, Hepatitis B, or Hepatitis C virus infection
    Reauthorization Requirements Documented in Policy: 3 of Documentation of disease stability;Meet Initial Criteria;Shows positive clinical response
    Does Policy Include Excluded Indications: Yes
    Supporting Documentation Requirements: 1 of Chart Notes;Medical Tests