Rituximab and hyaluronidase (Rituxan Hycela)


Indications for Prior Authorization:

  • Treatment of adult patients with:
    • Follicular Lymphoma (FL)
      • Relapsed or refractory, follicular lymphoma as a single agent
      • Previously untreated follicular lymphoma in combination with first line chemotherapy and, in patients achieving a complete or partial response to rituximab in combination with chemotherapy, as single-agent maintenance therapy
      • Non-progressing (including stable disease), follicular lymphoma as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy
    • Diffuse Large B-cell Lymphoma (DLBCL)
      • Previously untreated diffuse large B-cell lyphoma in combination with cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) or other anthracycline-based chemotherapy regimens
    • Chronic Lymphocytic Leukemia (CLL)
      • Previously untreated and previously treated CLL in combination with fludarabine and cyclophosphamide (FC)

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

  • Prescribed by an oncologist, AND
  • 18 years of age or older, AND
  • Patient will receive at least one full dose of Rituxan IV before starting Rituxan Hycela

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

  • Any other indication not listed above (e.g., non-malignant conditions: rheumatoid arthritis, granulomatosis with polyangiitis, microscopic polyangiitis)


  • All patients must receive at least one full dose of a rituximab product by IV infusion before receiving Rituxan Hycela by subcutaneous injection
  • FL/DLBCL: 1,400 mg/23,400 U subcutaneously according to recommended schedule
  • CLL: 1,600 mg/26,800 U subcutaneously according to recommended schedule
  • Premedicate with acetaminophen and antihistamine before each dose; consider premedication with glucocorticoids
  • Administered by a healthcare professional


  • Authorization will be issued for one course of therapy
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