- Step Therapy: Immune Thrombocytopenic Purpura (ITP):
ST Single Generic
- Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Duration: 6 Month(s)
- 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
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