- Immune Thrombocytopenic Purpura (ITP):
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Diagnosis Types: 1 of Chronic hepatitis C;Chronic Immune Thrombocytopenia
Reauthorization Requirements Documented in Policy: Show Response
Supporting Documentation Must Be Submitted: No
Severe Aplastic Anemia:
- Step Therapy: ST Single Generic
- Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Severe Aplastic Anemia:
PA Applies
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