- Prior Authorization: Chronic Lymphocytic Leukemia, Diffuse Large B-Cell Lymphoma, Graft Versus Host Disease (GVHD), Marginal Zone Lymphoma, Waldenstrom Macroglobulinemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Follicular Lymphoma (FL): Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Mantle Cell Lymphoma: Documented Diagnosis: Yes
Age Requirement: >= 18
Reauthorization Required: Yes
Non Hodgkin Lymphoma (NHL): Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- Chronic Lymphocytic Leukemia:
Age Requirement: >= 18
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: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
Concomitant Therapy Requirement: 1 of bendamustine and rituximab;obinutuzumab;rituximab
Diagnosis Types: 2 of as a single agent;Chronic Lymphocytic Leukemia;Small Lymphocytic Lymphoma
Diffuse Large B-Cell Lymphoma: Age Requirement: >= 18
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: N/A
Follicular Lymphoma (FL): Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: No
Duration of Reauthorization: N/A
Graft Versus Host Disease (GVHD): Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Bone Marrow Specialist;Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Mantle Cell Lymphoma: Age Requirement: >= 18
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Marginal Zone Lymphoma: Age Requirement: >= 18
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: Unspecified
Non Hodgkin Lymphoma (NHL): Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Waldenstrom Macroglobulinemia: Age Requirement: >= 18
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)
- Limited Access. Anti-Cancer: Maximum $200 copayment per State Law.
- Step Therapy: Graft Versus Host Disease (GVHD):
ST Single Generic
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