- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Step Therapy: ST Generic and Brand
- Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA):
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
Psoriatic Arthritis (PsA):
Duration: 12 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)
TB Test required: No
- Prior Authorization: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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