Belatacept (Nulojix)

Approved for Office Administration

Indications for Prior Authorization

  • kidney transplant

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee.

  • any other diagnosis not listed in the approved indications

All of the following must be met:

  • to prevent organ rejection in an adult (>18 yrs.) patient

AND

  • patient is EBV seropositive

Dosing

Initial

  • The recommended dose is up to 10 mg/Kg IV for six doses maximum over the first 12 weeks

Maintenance

  • Up to 5 mg/Kg IV every four weeks

The drug is approvable for coverage for one year.


Western Health Advantage Pharmacy and Therapeutics Committee

Approved:  December 2013 | Revised: July 2015

Last review date: July 20, 2016