- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 3 EA PER 30 day(s)
- Multiple Myeloma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of All NCCN indications with evidence level of 2A or higher;as maintenance following autologous hematopoietic stem cell transplantation;First line treatment in combination with Revlimid (lenalidomide) and dexamethasone;in combination with lenalidomide and dexamethasone for the treatment multiple myeloma after at least one prior therapy. ;Newly diagnosed and eligible for stem cell transplant;Primary therapy for symptomatic disease
Concomitant Therapy Requirement: in combination with lenalidomide and dexamethasone
- Orally administered anticancer medication.
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