Prior authorization criteria for:
Campath®
(alemtuzumab)
COVERED USES:
FDA Approved Indications:
Campath® is indicated as a single agent for the treatment of B-cell chronic lymphocytic leukemia (B-CLL).
AGE RESTRICTIONS:
NA
PRESCRIBER RESTRICTIONS:
NA
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:
Campath® is approved, subject to benefits, for patients who meet the following:
- Documented clinical diagnosis of B-cell chronic lymphocytic leukemia (204.1_)
- Administer prophylaxis against Pneumocystis jiroveci pneumonia (PCP) and herpes virus infections.
- Doses limited to 20mg (single) and 90mg (cumulative weekly)
EXCLUSION CRITERIA:
NA
COVERAGE DURATION:
Initial authorization and reauthorization will be approved for up to one year.