Criteria for use:

• Service Line: hematology, primary service (continuation of home medication)
• Service Location: Inpatient
• Patient Population: Adults, pediatric patients age 1 year and older

• Prior Authorization Required: yes, for outpatient prescription
• Criteria of Use/Restriction:
  • Continuation of home medication/outpatient treatment
  • New start:
    • Restrict to hematology service line for new starts,

     AND

• • • Confirming patient access to medication upon discharge (i.e. work on the prior authorization process)

    AND one of the following:

• • • Failure of first line therapies for severe aplastic anemia and ITP
    • In combination with standard immunosuppressive therapy for the first-line treatment of adult and pediatric patients 2 years and older with severe aplastic anemia

Local P&T will determine to stock or not stock and submit HUB IS tickets accordingly.

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