- Multiple Myeloma:
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: Payer Specific
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of Double refractory to a PI and an immunomodulatory agent;Monotherapy after at least 3 prior lines of therapy including a PI and an immunomodulatory agent;newly diagnosed and ineligible for autologous stem cell transplant;patients who have received at least one prior therapy;patients who received at least 2 prior therapies including lenalidomide and a proteasome inhibitor
Concomitant Therapy Requirement: 1 of in combination with bortezomib and dexamethasone;in combination with bortezomib, melphalan and prednisone;in combination with lenalidomide and dexamethasone;in combination with pomalidomide and dexamethasone
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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