OH Epic Formulary, available via treatment plan, restricted to:

• Indication:
  • Treatment of adult patients with large B-cell lymphoma (LBCL), including diffuse large B-cell lymphoma (DLBCL) not otherwise specified (including DLBCL arising from indolent lymphoma), high-grade B- cell lymphoma, primary mediastinal large B-cell lymphoma, and follicular lymphoma grade 3B who have:
    • Refractory disease to first-line chemoimmunotherapy or relapse within 12 months of first-line chemoimmunotherapy; or
    • refractory disease to first-line chemoimmunotherapy or relapse after first-line chemoimmunotherapy and are not eligible for hematopoietic stem cell transplantation (HSCT) due to comorbidities or age; or
    • Relapsed or refractory disease after two or more lines of systemic therapy.
  • Treatment of adult patients with relapsed or refractory chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) who have received at least 2 prior lines of therapy, including a Bruton tyrosine kinase (BTK) inhibitor and a B-cell lymphoma 2 (BCL-2) inhibitor.
• Service line: Oncology/Hematology
• Formulary location: Inpatient, outpatient infusion
• Service location: Inpatient, outpatient infusion
• Patient population: Adults
• Prior authorization required: Yes, Single Case Agreement
• Restriction/criteria of use (all will apply unless specified):
  • Use under one of FDA-approved indications above
  • Radiographically documented disease
  • Not diagnosed with primary central nervous system lymphoma
  • Negative pregnancy test
  • Eastern Cooperative Oncology Group performance status of 0-1
  • Healthcare facilities that dispense and administer Breyanzi must be enrolled and comply with the BREYANZI REMS requirements.

• UpToDate
• Lexicomp
• DailyMed Package Inserts
• Johns Hopkins Guides