- 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 AHFS Guidelines;FDA Approved Indications;NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of All FDA-approved indications;in combination with bortezomib and dexamethasone for the treatment of multiple myeloma after at least 2 prior regimens, including bortezomib and an immunomodulatory agent
Concomitant Therapy Requirement: 1 of in combination with bortezomib and dexamethasone;in combination with carfilzomib;in combination with lenalidomide and dexamethasone
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Duration: 1 year(s)
- 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;
- Quantity Limit: 1 capsule per 1 day(s).
- PA Applies
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