- Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Thrombocytopenia In Chronic Liver Disease:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
- Immune Thrombocytopenic Purpura (ITP):
Age Requirement: >= 18
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 1 year(s)
Diagnosis Types: 1 of Chronic Immune Thrombocytopenia;Immune Thrombocytopenic Purpura
Baseline Platelet Count: < 30,000/mcL
Reauthorization Requirements Documented in Policy: Platelet count >=50,000/mcL and <=100,000/mcL
Required Medical Information: 2 of Documentation of diagnosis;Platelet count
Supporting Documentation Must Be Submitted: Yes
Thrombocytopenia In Chronic Liver Disease:
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): 1 of Accredo Health Group, Inc.;Apothecary By Design;Circle Care;The Pharmacy at Maine Medical Center
Reauthorization Required: No
Duration of Reauthorization: N/A
- Step Therapy: Immune Thrombocytopenic Purpura (ITP):
ST Single Generic
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