- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: < 19
Duration: 12 Month(s)
Reauthorization Required: Yes
Aggressive Systemic Mastocytosis (ASM): Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Orally administered anticancer medication.
- Acute Myeloid Leukemia:
Age Requirement: < 19
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
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
Use of Biomarkers in Policy: FLT3 mutation
Diagnosis Types: 2 of FLT3 mutation-positive AML detected by FDA-approved test;Induction therapy OR Consolidation therapy ;Medically accepted uses supported by NCCN Category 1, 2A or 2B level of evidence
Excludes Coverage in Maintenance Setting: No
Aggressive Systemic Mastocytosis (ASM): Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Quantity Limit: limit maximum 8 EA PER 1 day(s)
|