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Alecensa (alectinib) — CareFirst (Caremark)

Large B-Cell Lymphoma (LBCL)

Initial criteria

  • Authorization may be granted for treatment of relapsed/refractory ALK-positive large B-cell lymphoma.

Reauthorization criteria

  • Authorization may be granted for continued treatment when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Approval duration

12 months