Bleomycin Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

• Squamous cell carcinoma of the head and neck
  
• Palliative treatment of Hodgkins lymphoma
  
• Palliative treatment of squamous cell carcinoma of nasopharynx
  
• Sclerosing treatment of malignant pleural effusions and the prevention of recurrence of pleural effusions
  
• Palliative treatment of Non-Hodgkins lymphoma
  
• Palliative treatment of squamous cell cervical cancer
  
• Palliative treatment of squamous cell carcinoma of the penis
  
• Palliative treatment of squamous cell carcinoma of the vulva
  
• Palliative treatment of testicular cancer

Exclusion Criteria

None

Required Medical Information

None

Age Restrictions

None

Prescriber Restrictions

None

Coverage Duration

Every prescription is authorized for up to six (6) months depending on refills written in prescription

Other Criteria

None