Rituxan
| Covered Uses: | All FDA approved indications not otherwise excluded from Part D. Additional coverage for off-label use is provided for relapsed or refractory Waldenstrom’s macroglobulinemia. |
| Exclusion Criteria: | Coverage is not provided for use of Rituxan in combination with other biologics e.g., Humira, Kineret or Remicade, etc. |
| Required Medical Information: | |
| Age Restrictions: | For rheumatoid arthritis: 18 years of age or older |
| Prescriber Restrictions: | |
| Coverage Duration: | 1 month for rheumatoid arthritis, 12 months for other indications |
| Other Criteria: | For rheumatoid arthritis: must be used in combination with MTX and after inadequate response or intolerance to at least one TNF inhibitor. Coverage is provided for Antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (e.g., Wegener’s Granulomatosis (WG) or Microscopic Polyangiitis (MPA)) when used in combination with glucocorticoids. |
Last Modified on 12/19/2012