NULOJIX (belatacept)

NULOJIX (belatacept

OFFICE ADMINISTRATION

Indications for Prior Authorization:

• Kidney transplant

Patients must meet the following criteria for the indication(s) above::

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

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 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

Approval:

Up to one year