COVERED USES:

FDA Approved Indications:

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

Off Label Approved Indications:

• Hodgkin's Lymphoma (201._)
• Breast cancer (174._)
• Chronic Myelocytic Leukemia (205.1_)
• Endometrial carcinoma(182.0)
• Melanoma (172._)
• Osteosarcoma (170._, 198.5)
• Prostate cancer (185)
• Soft Tissue Sarcomas (171._)
• Testicular cancer (186._)
• Waldenstrom Macroglobulinemia (273.3)

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:

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:

See Covered Uses.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be for up to 6 months