- Quantity Limits Apply
- Immune Thrombocytopenic Purpura (ITP):
Age Requirement: >= 1
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: 1 of Chronic hepatitis C;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: 3 of Meet Initial Criteria;Platelet count < 400,000/mcL;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
Severe Aplastic Anemia:
Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
- Step Therapy: Immune Thrombocytopenic Purpura (ITP):
ST Multiple Generics
- Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 1
Duration: 6 Month(s)
Reauthorization Required: Yes
Severe Aplastic Anemia:
Age Requirement: >= 2
Duration: 6 Month(s)
- New commercial members to be referred to AcariaHealth Limited Access.
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