- Step Therapy: ST Required
- Quantity Limit: 24 tablets per 30 day(s).
- Quantity Limit: limit maximum 60 EA PER 30 day(s)
- May be covered under Medical Benefit.
- Prior Authorization: CIDP: Immune Globulin:
PA Applies
Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Pemphigus Vulgaris:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
PID: Immune Globulin:
Duration: 6 Month(s)
- Assisted Reproductive Technology (ART):
Age Requirement: >= 18
Duration: 6 Month(s)
Gender Requirement: Female
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
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