HealthNet - All plan years
Macugen (pegaptanib)
Drugs for the Eye : Drugs for the Eye
  • Prior Authorization: Acromegaly, Oncology: Carcinoid Syndrome:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

    Neuroendocrine Tumor (NET):
    Documented Diagnosis: Yes

  • Available only through Specialty Pharmacy;
  • Immune Thrombocytopenic Purpura (ITP):
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Hematologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Diagnosis Types: Chronic Immune Thrombocytopenia
    Baseline Platelet Count: 1 of < 30,000/mcL;Active bleed
    Risk of Bleeding as defined in policy: As indicated by platelet count < 30,000/mcL
    Reauthorization Requirements Documented in Policy: 2 of Meet Initial Criteria;Response to therapy as evidenced by increased platelet count
    Required Medical Information: 3 of Chart Notes;Lab Results;Platelet count
    Supporting Documentation Must Be Submitted: Yes

    Thrombocytopenia In Chronic Liver Disease:
    Age Requirement: >= 18
    Duration: 14 Day(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Gastroenterologist;Hematologist;Hepatologist
    Reauthorization Required: No
    Duration of Reauthorization: N/A