- PA Applies
- Graft Versus Host Disease (GVHD), Secondary Progressive Multiple Sclerosis:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Granulomatosis with Polyangiitis: Age Requirement: >= 2
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): IngenioRx Specialty Pharmacy
Reauthorization Required: No
Duration of Reauthorization: N/A
Immune Thrombocytopenic Purpura (ITP): Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Types: Immune Thrombocytopenic Purpura
Required Medical Information: 2 of Documentation of diagnosis;Medication History
Supporting Documentation Must Be Submitted: Yes
Microscopic Polyangiitis (MPA): Age Requirement: >= 2
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Multiple Sclerosis (MS): Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
Myasthenia Gravis: Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Pemphigus Vulgaris: Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): IngenioRx Specialty Pharmacy
Reauthorization Required: No
Duration of Reauthorization: N/A
Rheumatoid Arthritis (RA): Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: No
- 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; Dosing Limit: See clinical criteria for details;
- Prior Authorization: Graft Versus Host Disease (GVHD), Immune Thrombocytopenic Purpura (ITP), Multiple Sclerosis (MS), Secondary Progressive Multiple Sclerosis:
Documented Diagnosis: Yes
Duration: 1 year(s)
Granulomatosis with Polyangiitis, Microscopic Polyangiitis (MPA): Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 1 year(s)
Myasthenia Gravis, Pemphigus Vulgaris, Rheumatoid Arthritis (RA): Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 year(s)
- 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
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