- 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
- 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
- Available only through Specialty Pharmacy;
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