- Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHlth SP pharmacy SF Split Fill
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
- Multiple Myeloma:
Age Requirement: >= 18
Duration: 1 plan year
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
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of All FDA-approved indications;All NCCN indications with evidence level of 2A or higher;in combination with dexamethasone after at least two prior therapies including lenalidomide and a proteasome inhibitor and demonstrated disease progression on or within 60 days of completion of the last therapy;Patients who have received at least 2 prior regimens including a PI and an immunomodulatory agent
Concomitant Therapy Requirement: in combination with dexamethasone
|