- Step Therapy: CIDP: Immune Globulin, Immune Thrombocytopenic Purpura (ITP):
ST Generic and Brand
Pemphigus Vulgaris:
ST Multiple Brands
PID: Immune Globulin:
ST Single Brand
- Prior Authorization: CIDP: Immune Globulin:
PA Applies
Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Pemphigus Vulgaris, PID: Immune Globulin:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- CIDP: Immune Globulin:
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Progressive or Relapsing Disease Course Required: Yes
Electrodiagnostic Evidence of Demyelination Required: Yes
Supporting Documentation Requirements: 2 of Chart Notes;Medical Tests
Immune Thrombocytopenic Purpura (ITP):
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Hematologist
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Types: 1 of Chronic Immune Thrombocytopenia;Immune Thrombocytopenic Purpura
Baseline Platelet Count: -1 of < 30,000/mcL;Active bleed
Risk of Bleeding as defined in policy: Unspecified
Required Medical Information: Platelet count
Supporting Documentation Must Be Submitted: No
Pemphigus Vulgaris:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
PID: Immune Globulin:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Immunologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Documented inability to mount an immune response: Yes
Documentation of severe infection despite prophylactic ABX treatment: Yes
Documented Serum IgG Level: N/A
IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: N/A
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