- Prior Authorization: Gaucher Disease:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Step Therapy: Graft Versus Host Disease (GVHD), Immune Thrombocytopenic Purpura (ITP), Secondary Progressive Multiple Sclerosis:
ST Single Brand
Myasthenia Gravis:
ST Multiple Generics
Rheumatoid Arthritis (RA):
ST Multiple Brands
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
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