Anthem Blue Cross (HMO, PPO, EPO)
Privigen (immun glob G(IgG)-pro-IgA 0-50)
Biological Agents : Biological Agents
  • 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;
  • PA Applies
  • Prior Authorization: CIDP: Immune Globulin:
    PA Applies Immune Thrombocytopenic Purpura (ITP), PID: Immune Globulin:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 1 year(s)

    Pemphigus Vulgaris:
    Documented Diagnosis: Yes
    Duration: 1 year(s)

  • CIDP: Immune Globulin:
    Duration: 12 week(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    Progressive or Relapsing Disease Course Required: No
    Electrodiagnostic Evidence of Demyelination Required: Yes
    Supporting Documentation Requirements: Medical Tests

    Immune Thrombocytopenic Purpura (ITP):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Diagnosis Types: Immune Thrombocytopenic Purpura
    Baseline Platelet Count: 1 of < 30,000/mcL;Active bleed
    Required Medical Information: 2 of Medication History;Platelet count
    Supporting Documentation Must Be Submitted: Yes

    Pemphigus Vulgaris:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    PID: Immune Globulin:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Documented inability to mount an immune response: Yes
    Documentation of severe infection despite prophylactic ABX treatment: No
    Documented Serum IgG Level: Unspecified
    IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: > 2
    Supporting Documentation Requirements: Medical Tests

  • Step Therapy: CIDP: Immune Globulin, PID: Immune Globulin:
    ST Single Brand

    Immune Thrombocytopenic Purpura (ITP):
    ST Multiple Brands

    Pemphigus Vulgaris:
    ST Single Generic

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