UnitedHealthcare
Zydelig (idelalisib)
Drugs for Cancer : Drugs for Cancer
  • Prior Authorization: Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Quantity Limit: limit maximum 2 EA PER 1 day(s)
  • Orally administered anticancer medication.
  • Chronic Lymphocytic Leukemia:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Diagnosis Types: 2 of Chronic Lymphocytic Leukemia;CLL for relapsed/refractory disease;Small Lymphocytic Lymphoma

    Diffuse Large B-Cell Lymphoma, Follicular Lymphoma (FL), Marginal Zone Lymphoma, Non Hodgkin Lymphoma (NHL):
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)