| Anthem Blue Cross (HMO, PPO, EPO) |
| Ninlaro (ixazomib) |
| Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Duration: 1 year(s)
- PA Applies
- Quantity Limit: 3 capsules per 28 day(s).
- 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: NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 2 of All NCCN indications with evidence level of 2A or higher;Multiple Myeloma;Patients who have received at least 2 prior regimens including a PI and an immunomodulatory agent;patients who have received at least one prior therapy;patients with disease progression on or within 60 days of completion of the last therapy
Concomitant Therapy Requirement: 1 of in combination with cyclophosphamide and dexamethasone;in combination with dexamethasone;in combination with lenalidomide and dexamethasone;in combination with pomalidomide and dexamethasone
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location; Limited access;
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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