- Prior Authorization: Acute Lymphoblastic Leukemia, Chronic Myelogenous Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Gastrointestinal Stromal Tumor, Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: Gastrointestinal Stromal Tumor:
ST Multiple Brands
- Acute Lymphoblastic Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): 1 of Avella Specialty Pharmacy;BriovaRx
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: Ph+ ALL
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Y
Chronic Myelogenous Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Gastrointestinal Stromal Tumor:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): BriovaRx
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Soft Tissue Sarcoma:
Duration: 12 Month(s)
Reauthorization Required: Yes
Medical Test Required: No
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 1 of All medically accepted indications;Gastrointestinal stromal tumor (GIST)
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
- Orally administered anticancer medication.
- Quantity Limit: limit maximum 4 EA PER 1 day(s)
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