Rituximab

Rituximab (anti-CD20 IgG1) is covered for multiple FDA-approved hematologic and autoimmune indications, including various CD20-positive B-cell non-Hodgkin lymphomas (in specified settings), chronic lymphocytic leukemia (with FC), rheumatoid arthritis (with methotrexate after TNF antagonist failure), and granulomatosis with polyangiitis/microscopic polyangiitis (with glucocorticoids). A broad set of off-label uses (e.g., ITP, Evans syndrome, refractory TTP, autoimmune neurologic conditions, PTLD, EBV viremia in high-risk transplant patients) are accepted by this A/B MAC, while other off-label uses may be considered at the A/B MAC's discretion; the policy does not list specific documentation or frequency limits and those should be confirmed with the A/B MAC.

"Rituximab is covered as a single agent for relapsed or refractory, low-grade or follicular, CD20-positive B-cell non-Hodgkin lymphoma (NHL)."