Health Net
Xigduo XR (dapagliflozin-metformin)
Hormones : Drugs for Diabetes
  • Quantity Limit: limit maximum 3 EA PER fill retail
  • Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA):
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes

    Crohn's Disease (CD), Ulcerative Colitis (UC):
    Age Requirement: >= 6
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes

    Psoriasis (PsO):
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes
    History of Plaque Psoriasis: N/A
    Overall % of Body Surface For Initiation: 3
    Overall % of Body Surface For Initiation With Sensitive Areas: Unspecified
    Psoriasis Classification: Moderate-Severe
    Sensitive Area BSA Percent override: Yes

    Uveitis:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified