- Zero Copay;
- Prior Authorization: Pain Narcotic: Opioid:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- PA Applies
- Atopic Dermatitis (Eczema):
Age Requirement: >= 12
Duration: 8 week(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 8 week(s)
Initial Authorization - POEM Values: N/A
Initial Authorization - SCORAD Values: N/A
Initial Authorization - EASI Values: N/A
Initial Authorization - IGA Values: N/A
Initial Authorization - PGA Values: N/A
Initial Authorization - ISGA Values: N/A
Initial Authorization - BSA Values: N/A
Physician Attestation for Initiation Required: No
Step Trial Length Period: Variable
Reauthorization Assessment Required: None
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