| Anthem Blue Cross (HMO, PPO, EPO) |
| Gammagard S/D (immun glob G-gly-gluc-IgA 0-50) |
| Biological Agents : Biological Agents |
- 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
- Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
- Step Therapy: Immune Thrombocytopenic Purpura (ITP):
ST Multiple Brands
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