Health Net
Venclexta Starting Pack (venetoclax)
Drugs for Cancer : Drugs for Cancer
  • 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