- Orally administered anticancer medication.
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Multiple Myeloma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of All NCCN indications with evidence level of 2A or higher;in combination with dexamethasone after at least two prior therapies including lenalidomide and a proteasome inhibitor and demonstrated disease progression on or within 60 days of completion of the last therapy;Patients who have received at least 2 prior regimens including a PI and an immunomodulatory agent
Concomitant Therapy Requirement: in combination with dexamethasone
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