- Acute Myeloid Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Quantity Limit: N/A
Criteria for Reauthorization: No evidence of disease progression or unacceptable toxicity
Diagnosis Types: 2 of Comorbidities that preclude the use of intensive induction chemotherapy;Medically accepted uses supported by NCCN Category 1, 2A or 2B level of evidence;Newly diagnosed acute myeloid leukemia;Newly diagnosed AML and age >=75;Newly diagnosed AML in combination with low-dose cytarabine;Relapsed or refractory disease (in relapse later than 12 months) after initial successful induction regimen
Excludes Coverage in Maintenance Setting: No
- Orally administered anticancer medication.
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
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