- Immune Thrombocytopenic Purpura (ITP):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Diagnosis Types: Chronic Immune Thrombocytopenia
Baseline Platelet Count: 1 of < 30,000/mcL;Active bleed
Risk of Bleeding as defined in policy: As indicated by platelet count < 30,000/mcL
Reauthorization Requirements Documented in Policy: 2 of Platelet count >=50,000/mcL and <=100,000/mcL;Response to therapy as evidenced by increased platelet count
Required Medical Information: Platelet count
Supporting Documentation Must Be Submitted: Yes
Severe Aplastic Anemia:
Duration: 1 year(s)
- PA Applies
- 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;
- Quantity Limit: 3 tablets per 1 day(s).
- Step Therapy: Immune Thrombocytopenic Purpura (ITP):
ST Single Generic
- Prior Authorization: Immune Thrombocytopenic Purpura (ITP):
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Reauthorization Required: Yes
Severe Aplastic Anemia:
Duration: 1 year(s)
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