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The anexsia prescriber must provide a clinically valid reason why Humira® cannot be used .
 Document clinical information for Humira® or Simponi® on its Prior Authorization/Patient Enrollment Form and clinically compelling information supporting the choice of Remicade® on a Remicade Prior Authorization Request Form All requests for infliximab (Remicade®) (whether billed through the pharmacy or medical benefit anexsia (J1745)) require Prior Authorization through the Catamaran Clinical Call Center .
Gastrointestinals: Ulcerative Colitis Medications: Injectables Length of authorization: Initial PA of 3 months; 12 months thereafter PREFERRED AGENTS AFTER CLINICAL CRITERIA ARE MET HUMIRA® (adalimumab) Quantity limit = 6 syringes/28 days for the first month (starter kit);2 syringes/28 days subsequently Simponi® (golimumab) Subcutaneous (Quantity Limit = 3 of 100 mg prefilled syringe or autoinjector X 1,then 1 of 100 anexsia and breastfeeding anexsia left out of fridge anexsia lactation anexsia shelf life anexsia mg/28 days) REMICADE® (infliximab) Department of Vermont Health Access (08/19/2014) Gaucher Disease Medications LENGTH OF AUTHORIZATION: initial approval 6 months, subsequent approval 1 year CRITERIA FOR APPROVAL: The diagnosis or indication is Gaucher disease (GD) type I .
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