Restrictions:

• Formulary location: Inpatient, outpatient infusion
• Service Line: Transplant
• Service Location: Inpatient, outpatient infusion centers
• Prior Authorization Required: yes for outpatient infusion
• Criteria of Use/Restriction: (All applies, unless specified)

Outpatient (infusion)

• Indication: Prophylaxis of organ rejection
• AND the following:
  • Adult patient 18 years and older receiving kidney transplant
  • Use only in EBV IgG seropositive
  • TB screening (QuantiFERON) prior to therapy initiation with documented negative results within the last 3 months

Inpatient

• One of the following indications:
  • New Start: Prophylaxis of organ rejection (de novo or conversion)
  • Continuation from home therapy: unable to receive infusion +/- 3 days of scheduled infusion
• AND the following:
  • Adult patient 18 years and older receiving kidney transplant
  • Use only in EBV IgG seropositive
  • TB screening (QuantiFERON) prior to therapy initiation with documented negative results within the last 3 months
  • New start - Outpatient set up completed (BMS PAT number, prior authorization, appointments set up for outpatient infusions)

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