- Anti-Cancer:Maximum $200 copayment per State Law.
- Acute Myeloid Leukemia:
Age Requirement: >= 18
Duration: 12 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: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: Chart Notes
Quantity Limit: N/A
Criteria for Reauthorization: Member is responding positively to therapy
Diagnosis Types: 2 of in combination with either azacitidine, decitabine, or cytarabine;Newly diagnosed AML and unable to tolerate intensive therapy;Newly diagnosed with AML and age >= 60;Relapsed/Refractory acute myeloid leukemia;Single agent use
Excludes Coverage in Maintenance Setting: No
Chronic Lymphocytic Leukemia: Age Requirement: >= 18
Duration: 12 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: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 1 of Chart Notes;Lab Tests
Concomitant Therapy Requirement: 1 of obinutuzumab;rituximab
Diagnosis Types: 2 of as a single agent;Chronic Lymphocytic Leukemia;CLL for relapsed/refractory disease;first line in combination;in combination with rituxumab;Small Lymphocytic Lymphoma
Multiple Myeloma: Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: NCCN Guidelines
ECOG Score Requirement in Policy: N/A
ECOG status <=2: No
Diagnosis Types: 1 of All NCCN indications with evidence level of 2A or higher;In combination with dexamethasone for relapsed or progressive multiple myeloma which has been previously treated and patient has t(11:14) translocation
Concomitant Therapy Requirement: in combination with dexamethasone
- Prior Authorization: Acute Myeloid Leukemia, Chronic Lymphocytic Leukemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
Multiple Myeloma: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
|