Zydelig

Drug - Zydelig® (idelalisib) [Gilead Siciences, Inc.]

April 2015

Therapeutic Area - Oncology

Criteria

• Patient has a diagnosis of chronic lymphocytic leukemia (CLL) when criteria A and B below are met:
  • At least one prior therapy for CLL has been ineffective AND
  • Idelalisib will be administered in combination with rituximab (Rituxan) OR
• Patient has a diagnosis of follicular B-cell non-Hodgkin lymphoma (FL) when criteria A and B below are met:
  • At least two prior therapies for FL have been ineffective AND
  • Idelalisib will be used as a monotherapy OR
• Patient has a diagnosis of  small lymphocytic lymphoma (SLL) when criteria A and B below are met:
  • At least two prior therapies for SLL have been ineffective AND
  • Idelalisib will be used as a monotherapy

Quantity limit

68 tablets per month

Questions?

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