Western Health Advantage
IDHIFA (enasidenib)
Drugs for Cancer : Drugs for Cancer
  • EDS due to OSA, Narcolepsy Type 1, Narcolepsy Type 2:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Neurology: Narcolepsy:
    Duration: 6 Month(s)
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Number of Episodes of Cataplexy Required in Policy: N/A
    Documented Duration of Daily EDS Occurrences: N/A
    Other causes of sleepiness have been ruled out.: No
    Patient must have CSF hypocretin 1 deficiency: No
    Patient Does Not Have a Deficiency of Succinic Semialdehyde Dehydrogenase: No
    Patient Does Not Have a History of Substance Abuse: No
    Patient is Not Using a Sedative Hypnotic: No
    Patient Will Not Be Using with Alcohol: No
    Documentation Requiring Patient to be Enrolled in REMS Success Program: No
    Documentation of prescriber enrollment in REMS program: No
    Prescriber Must Check Patient's Drug History on Controlled Substance Database: No
    Documented Time Period or Frequency of Time That the Precriber Must Regularly See the Patient: N/A
    Diagnosis Type(s): Unspecified
    Supporting Documentation Requirements: Diagnosis confirmed by sleep lab evaluation
    Documented Diagnosis: Yes
    Patient has >1 Cataplexy Episodes: No
    Documented Daily EDS occurrences >= 3 months: No
    MSLT <8min with evidence of 2 SOREMP's: No
    MSLT with evidence of >= 1 SOREMP's and SOREMP, 15 min from preceeding night PSG: No
    CSF Hypocretin-1 Deficiency: No
    Prescriber Must See Patient Every 3 Months: No

  • Prior Authorization: Erectile Dysfunction (ED):
    Duration: 1 year(s)

  • Split Fill;
  • Chronic Lymphocytic Leukemia:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: Payer Specific
    Diagnosis Types: 1 of Chronic Lymphocytic Leukemia;Small Lymphocytic Lymphoma

    Multiple Myeloma:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: NCCN Guidelines
    ECOG Score Requirement in Policy: N/A
    ECOG status <=2: No
    Diagnosis Types: 2 of Multiple Myeloma;Progressive disease;Relapsed disease