| Anthem Blue Cross (HMO, PPO, EPO) |
| Pomalyst (pomalidomide) |
| Drugs for Cancer : Drugs for Cancer |
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- Multiple Myeloma:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of in combination with daratumumab and dexamethasone in relapsed or refractory multiple myeloma after one to three lines of therapy;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;In combination with isatuximab-irfc plus dexamethasone in relapsed or refractory multiple myeloma after one to three lines of therapy
Concomitant Therapy Requirement: 1 of in combination with daratumumab and dexamethasone;in combination with dexamethasone;in combination with elotuzumab and dexamethasone;In combination with isatuximab-irfc plus dexamethasone
- PA Applies
- Prior Authorization: Multiple Myeloma:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Quantity Limit: 21 capsules per 28 day(s).
|