- PA Applies
- 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 For newly diagnosed or Primary treatment of multiple myeloma;patients who have received at least one prior therapy;Refractory disease;Relapsed disease
Concomitant Therapy Requirement: 1 of Cyclophosphamide, bortezomib and dexamethasone
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Duration: 1 year(s)
- 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;
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