- Anti-Cancer:Maximum $200 copayment per State Law.
- Multiple Myeloma:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 3 of All FDA-approved indications;All NCCN indications with evidence level of 2A or higher;in combination with bortezomib and dexamethasone after at least one prior therapy;In combination with carfilzomib and dexamethasone, for relapsed or refractory multiple myeloma who have received 1 to 3 prior lines of therapy;in combination with daratumumab and dexamethasone in relapsed or refractory multiple myeloma after one to three lines of therapy;in combination with dexamethasone for the treatment of relapsed or refractory multiple myeloma who have received at least four prior therapies and refractory to at least two proteasome inhibitors at least two immunomodulatory agents,and an anti-CD38 monoclonal antibody;in combination with pomalidomide and dexamethasone after at least two prior therapies including lenalidomide and a proteasome inhibitor;Multiple Myeloma;Progressive disease;Refractory disease;Relapsed disease
Concomitant Therapy Requirement: 1 of in combination with bortezomib and dexamethasone;in combination with carfilzomib and dexamethasone;in combination with daratumumab and dexamethasone;in combination with dexamethasone;in combination with pomalidomide and dexamethasone
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
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