Rasburicase Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

Initial management of plasma uric acid levels in pediatric patients with solid tumor malignancies, leukemia or lymphoma who are receiving chemotherapy expected to cause tumor lysis and subsequent increased plasma uric acid levels

Exclusion Criteria

(a) None

Required Medical Information

(a) None

Age Restrictions

(a) None

Prescriber Restrictions

(a) None

Coverage Duration

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

Other Criteria

(a) None