- CIDP: Immune Globulin:
Duration: 12 week(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Progressive or Relapsing Disease Course Required: No
Electrodiagnostic Evidence of Demyelination Required: Yes
Supporting Documentation Requirements: Medical Tests
Immune Thrombocytopenic Purpura (ITP):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Types: Immune Thrombocytopenic Purpura
Baseline Platelet Count: 1 of < 30,000/mcL;Active bleed
Required Medical Information: 2 of Medication History;Platelet count
Supporting Documentation Must Be Submitted: Yes
Pemphigus Vulgaris:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
PID: Immune Globulin:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Documented inability to mount an immune response: Yes
Documentation of severe infection despite prophylactic ABX treatment: No
Documented Serum IgG Level: Unspecified
IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: > 2
Supporting Documentation Requirements: Medical Tests
- Step Therapy: Diabetic Medical Supplies:
ST Multiple Brands
- Rheumatoid Arthritis (RA):
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
TB Test required: Yes
- Step Therapy: ST Single Generic
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