- Prior Authorization: Chronic Lymphocytic Leukemia, Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Graft Versus Host Disease (GVHD), Marginal Zone Lymphoma, Non Hodgkin Lymphoma (NHL), Waldenstrom Macroglobulinemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Immune Thrombocytopenic Purpura (ITP): Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Multiple Sclerosis (MS): Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Chronic Lymphocytic Leukemia:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
Diagnosis Types: 1 of Chronic Lymphocytic Leukemia;Small Lymphocytic Lymphoma
Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Graft Versus Host Disease (GVHD), Marginal Zone Lymphoma, Non Hodgkin Lymphoma (NHL), Waldenstrom Macroglobulinemia: Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Immune Thrombocytopenic Purpura (ITP): Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Unspecified
Reauthorization Required: Yes
Duration of Reauthorization: <= 12 month(s)
Diagnosis Types: Immune Thrombocytopenic Purpura
Baseline Platelet Count: <30,000/mcL with symptoms of bleeding
Risk of Bleeding as defined in policy: As indicated by platelet count < 30,000/mcL
Reauthorization Requirements Documented in Policy: Show Response
Required Medical Information: 2 of Chart Notes;Lab Results;Medical Test
Supporting Documentation Must Be Submitted: Yes
Multiple Sclerosis (MS): Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Appropriate Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Patients Cardiac Medical History Required: No
Concomitant use of other MS medication: No
Supporting Documentation Requirements: 2 of Chart Notes;Medication History
- Step Therapy: Immune Thrombocytopenic Purpura (ITP):
ST Multiple Generics
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