- PA Applies
- Available only through Specialty Pharmacy; 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;
- Chronic Lymphocytic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
Supporting Documentation Requirements: Lab Tests
Diagnosis Types: 1 of CLL with or without 17p deletion;Small Lymphocytic Lymphoma
Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Mantle Cell Lymphoma, Marginal Zone Lymphoma, Myelodysplastic Syndrome, Non Hodgkin Lymphoma (NHL):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
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 NCCN Guidelines;Payer Specific
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of as maintenance following autologous hematopoietic stem cell transplantation;As monotherapy;Multiple Myeloma in combination with dexamethasone
Concomitant Therapy Requirement: in combination with dexamethasone
- Quantity Limit: 1 capsule per 1 day(s).
- Prior Authorization: Chronic Lymphocytic Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Mantle Cell Lymphoma, Marginal Zone Lymphoma, Multiple Myeloma, Myelodysplastic Syndrome, Non Hodgkin Lymphoma (NHL):
Documented Diagnosis: Yes
Duration: 1 year(s)
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