- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Age Requirement: >= 75 in the scenario of Newly diagnosed treatment
Duration: 1 year(s)
Chronic Lymphocytic Leukemia:
Documented Diagnosis: Yes
Duration: 1 year(s)
- PA Applies
- May process through Pharmacy or Medical benefit depending on Patient location;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- Quantity Limit: 2 tablets per 1 day(s).
- Acute Myeloid Leukemia:
Is Medicare B vs D: No
Specialist Required: No
Unspecified PA: No
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Quantity Limit: N/A
Diagnosis Types: 2 of in combination with either azacitidine, decitabine, or cytarabine;Newly diagnosed AML and age >=75;Newly diagnosed AML and unable to tolerate intensive therapy in the scenario of Default
Diagnosis Types: 2 of in combination with either azacitidine, decitabine, or cytarabine;Newly diagnosed AML and age >=75 in the scenario of Newly diagnosed treatment
Diagnosis Types: 2 of in combination with either azacitidine, decitabine, or cytarabine;Newly diagnosed AML and unable to tolerate intensive therapy in the scenario of Ineligible for intensive induction chemotherapy
Excludes Coverage in Maintenance Setting: No
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: 1 of FDA Approved Indications;NCCN Guidelines
Concomitant Therapy Requirement: 1 of obinutuzumab;rituximab
Diagnosis Types: 2 of as a single agent;CLL for relapsed/refractory disease;CLL with or without 17p deletion;first line in combination;in combination with rituxumab;Small Lymphocytic Lymphoma
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