- Quantity Limits Apply
- Prior Authorization: Chronic Lymphocytic Leukemia, Follicular Lymphoma (FL), Mantle Cell Lymphoma, Marginal Zone Lymphoma, Multiple Myeloma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Myelodysplastic Syndrome:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Chronic Lymphocytic Leukemia:
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: Payer Specific
Supporting Documentation Requirements: Chart Notes
Diagnosis Types: 2 of Chronic Lymphocytic Leukemia;first line therapy;Second-line treatment ;Small Lymphocytic Lymphoma
Follicular Lymphoma (FL), Mantle Cell Lymphoma, Marginal Zone Lymphoma:
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)
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: FDA Approved Indications
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of All FDA-approved indications;All NCCN indications with evidence level of 2A or higher;As a single agent in steroid intolerant individuals with previously treated relapsed or progressive disease;as maintenance following autologous hematopoietic stem cell transplantation;Maintenance therapy as a single agent or in combination with bortezomib following ASCT;Maintenance therapy as a single agent or in combination with bortezomib for active myeloma after response to primary therapy;Multiple Myeloma in combination with dexamethasone
Concomitant Therapy Requirement: 1 of in combination with bortezomib;in combination with dexamethasone
Myelodysplastic Syndrome:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
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