Prior Authorization Required

Prior authorization is required. Typical authorizations are granted for 12 months when the criteria in the coverage section are met.

• Prior authorization required for all indications listed in the coverage criteria.
• Typical authorization duration: 12 months when criteria are met.

Refractory / Previous Therapy Considerations

Coverage for the requested medication in previously treated or refractory disease may depend on prior therapy exposure and documented refractory status. Review the specific regimen criteria in the coverage section for combinations that require prior therapies or refractory definitions.

• Lenalidomide- or bortezomib-refractory status: certain combination regimens are limited to members with documented refractory disease to lenalidomide or bortezomib as specified in the coverage criteria.
• Prior therapy requirements: some single-agent or combination uses require prior exposure to a proteasome inhibitor (PI) and an immunomodulatory agent, or at least three prior therapies, as detailed in the coverage criteria.
• Combinations with venetoclax require documented t(11;14) translocation where indicated.

Documentation Required

Submit documentation of testing or laboratory results confirming t(11;14) translocation when required by the coverage criteria.

• Provide cytogenetic or molecular testing reports confirming t(11;14) for indications or combinations (e.g., venetoclax combinations) that specify this requirement.

Non-covered Indications

Indications not listed in the FDA-approved or compendial uses (see compendial uses) are considered experimental/investigational and not medically necessary. Requests for such indications will be denied.

• Non-covered indications include any uses outside the FDA-approved and compendial list (e.g., indications not listed under Compendial Uses in the policy).
• If the requested use is not explicitly supported by the coverage criteria or compendia, it should be treated as investigational and will not be authorized.