- Step Therapy: Immune Thrombocytopenic Purpura (ITP):
ST Single Generic
- Available only through Specialty Pharmacy;
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;
- Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Immune Thrombocytopenic Purpura (ITP):
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Diagnosis Types: Chronic Immune Thrombocytopenia
Baseline Platelet Count: 1 of < 30,000/mcL;Active bleed
Reauthorization Requirements Documented in Policy: 2 of Platelet count >=50,000/mcL and <=100,000/mcL;Response to therapy as evidenced by increased platelet count
Required Medical Information: 2 of Documentation of diagnosis;Platelet count
Supporting Documentation Must Be Submitted: Yes
- PA Applies
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