- Quantity Limit: 30 day supply per 1 fill(s).
- Pemphigus Vulgaris:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
PID: Immune Globulin:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Documented inability to mount an immune response: Yes
Documentation of severe infection despite prophylactic ABX treatment: Yes
Documented Serum IgG Level: Unspecified
IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: > 2
Supporting Documentation Requirements: Medical Tests
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