- Quantity Limit: limit maximum 3 EA PER fill retail
- Prior Authorization: CIDP: Immune Globulin:
PA Applies
Immune Thrombocytopenic Purpura (ITP): Documented Diagnosis: Yes
Duration: 6 Month(s)
Pemphigus Vulgaris, PID: Immune Globulin: Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
|