Health Net
Privigen (immun glob G(IgG)-pro-IgA 0-50)
Biological Agents : Biological Agents
  • Step Therapy: CIDP: Immune Globulin, Immune Thrombocytopenic Purpura (ITP):
    ST Generic and Brand

    Pemphigus Vulgaris:
    ST Multiple Brands

    PID: Immune Globulin:
    ST Single Brand

  • 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

  • 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