- Acute Myeloid Leukemia:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Supporting Documentation Requirements: 2 of Chart Notes;FLT3 Mutation Evidence;Lab Tests
Quantity Limit: N/A
Criteria for Reauthorization: Member is responding positively to therapy
Use of Biomarkers in Policy: FLT3 mutation
Diagnosis Types: 2 of FLT3 mutation-positive AML detected by FDA-approved test;In combination with standard cytarabine and daunorubicin induction and cytarabine consolidation;Post induction therapy
Excludes Coverage in Maintenance Setting: Yes
Aggressive Systemic Mastocytosis (ASM): Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Allergist;Immunologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
- Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Aggressive Systemic Mastocytosis (ASM): Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
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