- Prior Authorization: Acute Lymphoblastic Leukemia, Chronic Lymphocytic Leukemia, Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Graft Versus Host Disease (GVHD), Marginal Zone Lymphoma, Waldenstrom Macroglobulinemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Granulomatosis with Polyangiitis, Microscopic Polyangiitis (MPA): Documented Diagnosis: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
Immune Thrombocytopenic Purpura (ITP): Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 Month(s)
Multiple Sclerosis (MS): Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Myasthenia Gravis, Non Hodgkin Lymphoma (NHL), Uveitis: Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Pemphigus Vulgaris, Rheumatoid Arthritis (RA): Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Acute Lymphoblastic 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: NCCN Guidelines
Diagnosis Types: Acute lymphoblastic leukemia
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Not Defined
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, 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: >= 2
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: 1 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Hematologist
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Types: Immune Thrombocytopenic Purpura
Baseline Platelet Count: 1 of < 30,000/mcL;Active bleed
Risk of Bleeding as defined in policy: As indicated by platelet count < 30,000/mcL
Reauthorization Requirements Documented in Policy: Reauthorization not covered
Required Medical Information: 3 of Documentation of diagnosis;Medication History;Platelet count
Supporting Documentation Must Be Submitted: No
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)
Non Hodgkin Lymphoma (NHL): 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)
Pemphigus Vulgaris: Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
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)
- Step Therapy: Acute Lymphoblastic Leukemia, Chronic Lymphocytic Leukemia, Diffuse Large B-Cell Lymphoma, Graft Versus Host Disease (GVHD), Granulomatosis with Polyangiitis, Immune Thrombocytopenic Purpura (ITP), Marginal Zone Lymphoma, Microscopic Polyangiitis (MPA), Myasthenia Gravis, Non Hodgkin Lymphoma (NHL), Pemphigus Vulgaris, Rheumatoid Arthritis (RA), Waldenstrom Macroglobulinemia:
ST Multiple Brands
Follicular Lymphoma (FL): ST Single Brand
Uveitis: ST Multiple Generics
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