- Prior Authorization: Alpha-1 Antitrypsin Deficiency:
PA Applies
- PA_APPLIES
- Diffuse Large B-Cell Lymphoma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Multiple Myeloma:
Duration: 1 year(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of 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;patients who have received at least one prior therapy
Concomitant Therapy Requirement: 1 of in combination with bortezomib and dexamethasone;in combination with dexamethasone
- QL (30 per Rx);
- Step Therapy: Neurology: Epilepsy:
ST Multiple Generics
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