Health Net
Zydelig (idelalisib)
Drugs for Cancer : Drugs for Cancer
  • Anti-Cancer:Maximum $200 copayment per State Law.
  • Prior Authorization: Chronic Lymphocytic Leukemia, Marginal Zone Lymphoma, Non Hodgkin Lymphoma (NHL):
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Follicular Lymphoma (FL):
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Step Therapy: Marginal Zone Lymphoma:
    ST Single Generic

  • 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: FDA Approved Indications
    Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
    Diagnosis Types: 1 of CLL for relapsed/refractory disease;Small Lymphocytic Lymphoma

    Follicular Lymphoma (FL):
    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)

    Marginal Zone Lymphoma:
    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)

    Non Hodgkin Lymphoma (NHL):
    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)