- Ankylosing Spondylitis (AS), Crohn's Disease (CD), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
Psoriasis (PsO):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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
Sensitive Area BSA Percent override: No
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;- Quantity Limit: 204 lancets per 30 day(s).
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