Health Net
Rituxan (rituximab)
Drugs for Cancer : Drugs for Cancer
  • 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