- Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
- Anti-Cancer: Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
- Psoriasis (PsO):
Duration: 1 year(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Dermatologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
TB Test required: No
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: N/A
Overall % of Body Surface For Initiation With Sensitive Areas: N/A
Psoriasis Classification: moderate to severe
Sensitive Area BSA Percent override: No
Psoriatic Arthritis (PsA): Duration: 1 year(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Dermatologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
TB Test required: No
- Prior Authorization: Growth Hormone Deficiency:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
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