| Anthem Blue Cross (HMO, PPO, EPO) |
| Hyqvia (IgG-hyaluronidase,recombinant) |
| Biological Agents : Biological Agents |
- Step Therapy: CIDP: Immune Globulin:
ST Single Brand
- CIDP: Immune Globulin:
Duration: 12 week(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Progressive or Relapsing Disease Course Required: No
Electrodiagnostic Evidence of Demyelination Required: Yes
Supporting Documentation Requirements: Medical Tests
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: No
Documented Serum IgG Level: Unspecified
IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: > 2
Supporting Documentation Requirements: Medical Tests
- Prior Authorization: CIDP: Immune Globulin:
PA Applies
PID: Immune Globulin:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- PA Applies
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