Transcription of PA Criteria - Universal American Medicare
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PA Criteria - Universal American Medicare
PA Criteria Prior Authorization Group ACITRETIN. Drug Names ACITRETIN. Covered Uses All FDA-approved indications not otherwise excluded from Part D, prevention of non-melanoma skin cancers in high risk individuals. Exclusion Criteria Required Medical Information Age Restrictions Prescriber Restrictions Coverage Duration Plan Year Other Criteria Prior Authorization Group ACTIMMUNE. Drug Names ACTIMMUNE. Covered Uses All FDA-approved indications not otherwise excluded from Part D, mycosis fungoides, Sezary syndrome, atopic dermatitis. Exclusion Criteria Required Medical Information Age Restrictions Prescriber Restrictions Coverage Duration Plan Year Other Criteria Prior Authorization Group ADAGEN. Drug Names ADAGEN. Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria Required Medical Information Age Restrictions Prescriber Restrictions Coverage Duration Plan Year Other Criteria Updated 09/01/2018 1.
Updated 08/01/2018 2 Prior Authorization Group ADEMPAS Drug Names ADEMPAS Covered Uses All FDA-approved indications not otherwise excluded from Part D. Exclusion Criteria
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