- Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: Immune Thrombocytopenic Purpura (ITP):
ST Single Generic
- Quantity Limit: limit maximum 15 EA PER 30 day(s)
- Immune Thrombocytopenic Purpura (ITP):
Age Requirement: >= 18
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Types: Chronic Immune Thrombocytopenia
Reauthorization Requirements Documented in Policy: Show Response
Supporting Documentation Must Be Submitted: No
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