Belatacept (Nulojix)

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


 

Last review date: July 20, 2016

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