- Available only through Specialty Pharmacy;
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;
- PA Applies
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Duration: 1 year(s)
- 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: 1 of Clinical Pharmacology;FDA Approved Indications;NCCN Guidelines;Wolters Kluwer Lexi-Drugs
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of in combination with lenalidomide plus dexamethasone in relapsed or refractory multiple myeloma after one to three line of therapy;in combination with pomalidomide and dexamethasone after at least two prior therapies including lenalidomide and a proteasome inhibitor;Other recommended regimens for previously treated multiple myeloma: elotuzumab, bortezomib, dexamethasone;Progressive disease;Refractory disease;Relapsed disease
Concomitant Therapy Requirement: 1 of in combination with bortezomib and dexamethasone;in combination with lenalidomide and dexamethasone;in combination with pomalidomide and dexamethasone
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