OH Epic Formulary, available via treatment plan.

Restricted to:

• Indication: Relapsed or refractory follicular lymphoma after two or more lines of systemic therapy
• Service line: Hematology/Oncology
• Formulary location: Inpatient (restricted), outpatient
• Service location: Inpatient (restricted), outpatient infusion
• Patient population: Patients ≥ 18 years old
• Prior authorization required: Yes for outpatient
• Restriction/criteria of use (all will apply unless specified):
  • Confirmed diagnosis of relapsed or refractory follicular lymphoma
  • Previously received 2 or more lines of systemic therapy
  • No history of CNS lymphoma or other CNS disease
  • No prior autologous stem cell transplant within 100 days prior or any prior allogeneic SCT or solid organ transplant
  • Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.
  • For inpatient use:
    
    • If patient experiences cytokine release syndrome (CRS) grade 2 or 3, admit under observation status to administer the next dose for 48-hour monitoring
    • May transition to inpatient status if monitoring extends past observation status allowances

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• Lexicomp
• DailyMed Package Inserts
• Johns Hopkins Guides