UnitedHealthcare |
Mavenclad (5 Tabs) (cladribine(multiple sclerosis)) |
Drugs for the Nervous System : Drugs for Multiple Sclerosis |
- Prior Authorization: Multiple Sclerosis (MS):
Documented Diagnosis: Yes
Duration: 2 Month(s)
Reauthorization Required: Yes
Secondary Progressive Multiple Sclerosis: Documented Diagnosis: Yes
Reauthorization Required: Yes
- Step Therapy: Multiple Sclerosis (MS):
ST Single Generic
Secondary Progressive Multiple Sclerosis: ST Single Brand
- Multiple Sclerosis (MS):
Duration: 2 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 2 month(s)
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
Secondary Progressive Multiple Sclerosis: Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
- Quantity Limit: limit maximum 40 EA PER 720 day(s)
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