- Quantity Limit: limit maximum 3 EA PER fill retail
- Prior Authorization: PA_APPLIES
- Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA):
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
TB Test required: No
Crohn's Disease (CD): Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Gastroenterologist
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: No
Psoriasis (PsO): Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
TB Test required: No
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: severe
Sensitive Area BSA Percent override: No
Psoriatic Arthritis (PsA): Duration: 6 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: = 6 month(s)
TB Test required: No
Ulcerative Colitis (UC): Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Gastroenterologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
TB Test required: No
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