Immune Globulin (IG) Therapy Medication and/or Infusion ...
http://www.aetna.com/pharmacy-insurance/healthcare-professional/documents/Immune-Globulin-Therapy-Medication-Precertification-Request-Form.pdf
Less than 30,000/mcL (30 x 10 9 /L) Greater than 30,000/mcL (30 x 10. 9 /L) Does the patient have significant bleeding symptoms (e.g., mucosal bleeding or other moderate to severe bleeding)? Yes . No . For Newly diagnosed, previously treated, chronic or persistent or ITP unresponsive to first line treatment: bleeding)? OR
DA: 93 PA: 44 MOZ Rank: 35