Health Net
Rituxan Hycela (rituximab-hyaluronidase,human)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Step Therapy: ST Single Brand

  • Chronic Lymphocytic Leukemia:
    Age Requirement: >= 18
    Duration: 6 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: 1 of FDA Approved Indications;NCCN Guidelines
    Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
    Diagnosis Types: Chronic Lymphocytic Leukemia

    Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Marginal Zone Lymphoma, Non Hodgkin Lymphoma (NHL):
    Age Requirement: >= 18
    Duration: 6 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)

<< Return | Back to top