- Quantity Limit: 30 day supply per 1 fill(s).
- Multiple Sclerosis (MS):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
- Prior Authorization: Diabetes Type 2: GLP1 + Combo:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: 2 fills per 365 day(s).
- Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
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
Psoriatic Arthritis (PsA): Age Requirement: >= 18
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
TB Test required: Yes
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