- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
- 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: 2 of in combination with bortezomib and dexamethasone for the treatment of multiple myeloma after at least 2 prior regimens, including bortezomib and an immunomodulatory agent;Multiple Myeloma
Concomitant Therapy Requirement: in combination with bortezomib and dexamethasone
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