- Multiple Myeloma:
Age Requirement: >= 18
Duration: 12 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
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 3 of All FDA-approved indications;All NCCN indications with evidence level of 2A or higher;as a single agent;as maintenance following autologous hematopoietic stem cell transplantation;Multiple Myeloma in combination with dexamethasone
Concomitant Therapy Requirement: 1 of in combination with dexamethasone;in combination with lenalidomide and dexamethasone;in combination with pomalidomide and dexamethasone
- Quantity Limit: Limit 3 capsules per month;QL(0.1 ea daily)
- Anti-Cancer:Maximum $200 copayment per State Law. Must use Exactus Specialty Rx.
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
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