Istodax® (romidepsin)

Authorization forms

Traditional, Optimized & Medicaid (03/2019)

No prior authorization is required for Medicare

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.