COVERED USES:

FDA Approved Indications:

• The treatment of patients with multiple myloma
• The treatment of patients with mantle cell lymphoma who have received at least one prior therapy

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

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

Must be prescribed by an oncologist.

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.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

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