Ninlaro (ixazomib) — CareFirst (Caremark)

Initial criteria

• Authorization of 12 months may be granted for treatment of Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma when the requested medication is prescribed in combination with rituximab 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