Bortezomib (Velcade)

OFFICE ADMINISTRATION

JCODE: J9041

Indications for Prior Authorization:

  • Multiple Myeloma
  • Relapsed or Refractory Mantle Cell Lymphoma*
  • Relapsed or Refractory Cutaneous or Peripheral T-cell Lymphoma*
  • Waldenstrom's Macroglobinemia**

* Patient has disease recurrence or progression on or following treatment with prior chemotherapy

** Must be given with rituximab

The drug is not covered for the following conditions:

  • Metastatic colorectal cancer
  • Advanced non-small cell lung cancer
  • Metastatic neuroendocrine carcinoma
  • Metastatic melanoma
  • Metastatic sarcoma
  • Any condition not listed in the indication section above

Dosing:

Previous untreated Multiple Myeloma

  • Cycle 1-4:  Up to 1.3 mg/m2 twice a week (IV/SubQ)
  • Cycles 5-9: Up to 1.3 mg/m2 once weekly (IV/SubQ)
  • *Each cycle is 6 weeks

Refractory or relapsed Multiple Myeloma or Mantle Cell Lymphoma

  • Up to 1.3 mg/m2 weekly (IV) for two weeks
  • Repeat every three weeks

Refractory or relapsed Cutaneous or T-cell Lymphoma

  • Up to 1.3 mg/m2 (IV) for up to four doses per 21 day cycle

Peripheral T-cell Lymphoma

  • Up to 1.3 mg/m2 (IV) for up to four doses per 21 day cycle

Waldenstrom's Macroglobinemia

  • Up to 1.3 mg/m2 (IV/SubQ)

Approval Period

Renew for one year if patient has clinical response


 

Last review date: July 20, 2016

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