For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;- Immune Thrombocytopenic Purpura (ITP):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Types: Chronic Immune Thrombocytopenia
Baseline Platelet Count: < 50,000/mcL
Reauthorization Requirements Documented in Policy: 2 of Platelet count >=50,000/mcL and <=100,000/mcL;Show Response
Required Medical Information: Platelet count
Supporting Documentation Must Be Submitted: Yes
- PA Applies
- Quantity Limit: 2 tablets per 1 day(s).
- Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
- Step Therapy: Immune Thrombocytopenic Purpura (ITP):
ST Single Generic
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