LUMOXITI (moxetumomab pasudotox-tdfk)

LUMOXITI (moxetumomab pasudotox-tdfk)

MEDICAL BENEFIT: INTRAVENOUS ADMINSTRATION

Indications for Prior Authorization:

• Indicated in adults with relapsed or refractory hairy cell leukemia (HCL) who received at least two prior systemic therapies, including treatment with a purine nucleoside analog

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

• Patient is ≥ 18 years of age, AND
• Prescribed by or in consultation with an oncologist or hematologist, AND
• Diagnosis of relapsed/refractory hairy cell leukemia confirmed by chart note documentation, AND
• Patient has received > 2 prior systemic therapies, including therapy with a purine analog (cladribine and/or pentostatin), AND
• Patient has an estimated creatinine clearance > 30 mL/min

Dosing:

• 0.04 mg/kg as a 30-minute IV infusion on days 1, 3, 5 of each 28-day cycle. 
• Continue Lumoxiti™ treatment for a maximum of 6 cycles, disease progression, or unacceptable toxicity

Approval:

• 6 months (maximum 6 total cycles)