- ST_APPLIES
- ST_APPLIES
- Hidradenitis Suppurativa (HS):
Age Requirement: >= 12
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Psoriasis (PsO):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 3
Overall % of Body Surface For Initiation With Sensitive Areas: 3
Psoriasis Classification: chronic.,moderate to severe
Sensitive Area BSA Percent override: No
Uveitis:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Step Therapy: Diabetic Medical Supplies:
ST Multiple Brands
- Zero Copay; $0 copay for members age 50 through 74, otherwise not covered;
- PA_APPLIES
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