8.2.76.1

Prior Authorization for Therapeutic Radiopharmaceuticals

Prior authorization is not required for therapeutic radiopharmaceuticals except for tositumomab or ibritumomab tiuxetan.

Tositumomab or ibritumomab tiuxetan may be prior authorized when all of the following criteria are met:

•	Client has a diagnosis of either a low‑grade follicular or transformed B‑cell non‑Hodgkin’s lymphoma.

•	Client has failed, relapsed, or become refractory to conventional chemotherapy and the following is documented:

•	Marrow involvement is less than 26 percent.

•	Platelet count is 100,000 cell/mm3 or greater.

•	Neutrophil count is 1,500 cell/mm3 or greater.

•	Client has failed a trial of rituximab.

Prior authorization must be submitted through Special Medical Prior Authorization department.

Only one tositumomab or ibritumomab tiuxetan (procedure codes A9542, A9543, A9544, and A9545) may be prior authorized and reimbursed once per lifetime, any provider with diagnosis code 20280.