Health Net
Gammagard S/D (immun glob G-gly-gluc-IgA 0-50)
Biological Agents : Biological Agents
  • Immune Thrombocytopenic Purpura (ITP):
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Hematologist
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Diagnosis Types: 1 of Chronic Immune Thrombocytopenia;Immune Thrombocytopenic Purpura
    Baseline Platelet Count: 1 of < 30,000/mcL;Active bleed
    Risk of Bleeding as defined in policy: Unspecified
    Required Medical Information: Platelet count
    Supporting Documentation Must Be Submitted: No

  • Step Therapy: Immune Thrombocytopenic Purpura (ITP):
    ST Single Generic

  • Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
    Documented Diagnosis: Yes
    Duration: 6 Month(s)

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