COVERED USES:

FDA Approved Indications:

• Malignant epithelial tumor of ovary, Nonresectable (palliative treatment) (183.0)
• Multiple myeloma, Palliative treatment (203.0_)

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:

The condition being treated meets the "COVERED USES" criteria above

For all indications, documentation of response to Alkeran must be submitted in order for continued authorization.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be for up to 6 months.