COVERED USES:

FDA Approved Indications:

Campath® is indicated as a single agent for the treatment of B-cell chronic lymphocytic leukemia (B-CLL).

All FDA-approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

Must be prescribed or recommended by hem/onc specialist.

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

• Documented clinical diagnosis of B-cell chronic lymphocytic leukemia (204.1_)
• Administer prophylaxis against Pneumocystis jiroveci pneumonia (PCP) and herpes virus infections.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to one year.