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