Sutter Health Plus
Psorcon (diflorasone)
Drugs for the Skin : Drugs for the Skin
  • Prior Authorization: Parkinson's Disease:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • PA_APPLIES
  • 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