Ninlaro (ixazomib) — CareFirst (Caremark)

Initial criteria

• Authorization of 12 months may be granted for treatment of multiple myeloma when any of the following criteria is met:
• The requested medication is prescribed in combination with lenalidomide and dexamethasone for patients who have received at least one prior therapy
• OR the requested medication is prescribed in combination with pomalidomide and dexamethasone for patients who have received at least two prior therapies including an immunomodulatory agent and a proteasome inhibitor if lenalidomide- or anti-CD-38 refractory
• OR the requested medication is prescribed in combination with cyclophosphamide and dexamethasone for patients who have received at least one prior therapy
• OR the requested medication is prescribed in combination with venetoclax and dexamethasone for patients with t(11;14) who have received at least one prior therapy
• OR the requested medication is prescribed as a substitute for bortezomib or carfilzomib when used as primary treatment or treatment for relapsed disease if the patient previously received the requested medication as primary induction therapy for non-transplant candidates

Reauthorization criteria

• Authorization of 12 months 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