COVERED USES:

FDA Approved Indications:

Velcade® is indicated for the treatment of:

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

Requests for a non-FDA approved (off-label) indication requires the proposed indication be listed in either the American Hospital Formulary System (AHFS), USP-DI, or Drugdex and is considered subject to evaluation of the prescriber's medical rationale, formulary alternatives, the available published evidence-based research and whether the proposed use is determined to be experimental/investigational.

AGE RESTRICTIONS:

N/A

PRESCRIBER RESTRICTIONS:

N/A

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:

Velcade® is approved, subject to benefits, for patients who meet the following:

• Diagnosis of multiple myeloma, OR
• Diagnosis of mantle cell lymphoma who have received at least one prior therapy

EXCLUSION CRITERIA:

N/A

COVERAGE DURATION:

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