Ninlaro (ixazomib) — CareFirst (Caremark)

Initial criteria

• Authorization of 12 months may be granted for treatment of relapsed or refractory systemic light chain amyloidosis when any of the following criteria is met:
• The requested medication is prescribed in combination with dexamethasone
• OR the requested medication is prescribed in combination with lenalidomide and dexamethasone
• OR the requested medication is prescribed in combination with cyclophosphamide and dexamethasone

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