Health Net
Truxima (rituximab-abbs)
Drugs for Cancer : Drugs for Cancer
  • Step Therapy: Immune Thrombocytopenic Purpura (ITP), Myasthenia Gravis, Uveitis:
    ST Multiple Generics

    Rheumatoid Arthritis (RA):
    ST Generic and Brand

  • Prior Authorization: Chronic Lymphocytic Leukemia, Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Graft Versus Host Disease (GVHD), Granulomatosis with Polyangiitis, Marginal Zone Lymphoma, Microscopic Polyangiitis (MPA), Non Hodgkin Lymphoma (NHL), Pemphigus Vulgaris, Waldenstrom Macroglobulinemia:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Immune Thrombocytopenic Purpura (ITP):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Multiple Sclerosis (MS):
    Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

    Myasthenia Gravis, Uveitis:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Rheumatoid Arthritis (RA):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Chronic Lymphocytic Leukemia:
    Age Requirement: >= 18
    Duration: 6 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
    Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
    Diagnosis Types: 1 of Chronic Lymphocytic Leukemia;Small Lymphocytic Lymphoma

    Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Graft Versus Host Disease (GVHD), Marginal Zone Lymphoma, Non Hodgkin Lymphoma (NHL), Waldenstrom Macroglobulinemia:
    Age Requirement: >= 18
    Duration: 6 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)

    Granulomatosis with Polyangiitis, Microscopic Polyangiitis (MPA):
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Immune Thrombocytopenic Purpura (ITP):
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Unspecified
    Reauthorization Required: Yes
    Duration of Reauthorization: <= 12 month(s)
    Diagnosis Types: Immune Thrombocytopenic Purpura
    Baseline Platelet Count: <30,000/mcL with symptoms of bleeding
    Risk of Bleeding as defined in policy: As indicated by platelet count < 30,000/mcL
    Reauthorization Requirements Documented in Policy: Show Response
    Required Medical Information: 2 of Chart Notes;Lab Results;Medical Test
    Supporting Documentation Must Be Submitted: Yes

    Multiple Sclerosis (MS):
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Appropriate Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Patients Cardiac Medical History Required: No
    Concomitant use of other MS medication: No
    Supporting Documentation Requirements: 2 of Chart Notes;Medication History

    Myasthenia Gravis:
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Appropriate Specialist
    Reauthorization Required: Yes
    Duration of Reauthorization: <= 12 month(s)

    Pemphigus Vulgaris:
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Dermatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Rheumatoid Arthritis (RA):
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Rheumatologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    TB Test required: No

    Uveitis:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

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