Sutter Health Plus
Kisqali (600 MG Dose) (ribociclib)
Drugs for Cancer : Drugs for Cancer
  • Anemia:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Dialysis status: Patients on dialysis and not on dialysis
    Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
    Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL OR TSAT >= 20% OR bone marrow demonstrates adequate iron stores
    Discontinuation requirements: Yes
    Documentation Requirements: blood pressure is adequately controlled before initiation and during therapy
    Titration Requirements: 1 of Maintain Hgb = 10 g/dL for non-dialysis patients;Maintain Hgb range 10 - 11 g/dL for dialysis patients

    Anemia due to Chemotherapy:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    Initial Therapy HgbHCT Requirements: Hgb < 10g/dL
    Initial Therapy Iron Stores Requirements: serum ferritin >= 100 ng/mL OR TSAT >= 20% OR bone marrow demonstrates adequate iron stores
    Diagnosis Types: 3 of anticipated outcome of chemotherapy is not cure;concomitant myelosuppresive chemotherapy;minimum of two additional months of planned chemotherapy;non-myeloid malignancy
    Dose Increase Requirements: No
    Discontinuation requirements: Yes

  • Quantity Limit: 1 package per 30 day(s).
  • 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;
  • Prior Authorization: Hemophilia A (Factor VIII):
    Duration: 1 year(s)