Empliciti

Drug - Empliciti™ (elotuzumab) [E.R.Squbb & Sons, L.L.C.]

January 2018

Therapeutic area - Oncology

Approval criteria

• Patient must be 18 years of age or older AND
• Have a diagnosis of multiple myeloma AND
• Must be used in combination with lenalidomide and dexamethasone AND
• Must have tried at least one other prior therapies for multiple myeloma
• Documentation of diagnosis from patient’s medical records must be provided at time of request

Quantity limits

• Dosing is based on weight. Patient’s most current weight must be provided at time of request
• Maximum of 10mg/kg according to the following dosing schedule:
  • Weekly: Weeks 1 to 8
  • Every two weeks: Weeks 9 onwards until disease progression or unacceptable toxicity

Approvals

• Initial approval will be limited to 6 months in duration
• Renewal approval will be limited to 6 months in duration
  • Documentation must be supplied at time of request showing patient is responsive to treatment

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411