- Quantity Limit: 2 capsules per 1 day(s).
- Step Therapy: ST_APPLIES
- Hemophilia A (Factor VIII):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Dosing Limit(s): N/A
Diagnosis Type(s): 1 of Mild to moderate;Severe
Diagnosis Treatments: 1 of Bleeding episodes;Routine propylaxis
Treatment Center Required: No
Hemophilia A or B with Inhibitor:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Dosing Limit(s): N/A
Diagnosis Type(s): 1 of Mild to moderate;Severe
Diagnosis Treatments: 1 of Bleeding episodes;Routine propylaxis
Treatment Center Required: No
Dosing Limits Exist: No
- Step Therapy: CIDP: Immune Globulin, PID: Immune Globulin:
ST Single Brand
Immune Thrombocytopenic Purpura (ITP):
ST Multiple Brands
Pemphigus Vulgaris:
ST Single Generic
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 morphine equivalent dose criteria click HERE
For details on quantity criteria click HERE
7 days supply per fill; 14 days supply per 30 days
For details on drug coverage click HERE;
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