- Step Therapy: ST Applies
- Immune Thrombocytopenic Purpura (ITP):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Hematologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Types: Chronic Immune Thrombocytopenia
Baseline Platelet Count: 1 of < 30,000/mcL;Active bleed
Risk of Bleeding as defined in policy: As indicated by platelet count < 30,000/mcL
Reauthorization Requirements Documented in Policy: 2 of Meet Initial Criteria;Response to therapy as evidenced by increased platelet count
Required Medical Information: 3 of Chart Notes;Lab Results;Platelet count
Supporting Documentation Must Be Submitted: Yes
Thrombocytopenia In Chronic Liver Disease:
Age Requirement: >= 18
Duration: 14 Day(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Gastroenterologist;Hematologist;Hepatologist
Reauthorization Required: No
Duration of Reauthorization: N/A
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