HealthNet - All plan years
Kymriah (tisagenlecleucel)
Drugs for Cancer : Drugs for Cancer
  • Acute Lymphoblastic Leukemia:
    Age Requirement: <= 25
    Duration: 3 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of Hematologist;Oncologist
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Diagnosis Types: 2 of R/R CD19+ B-cell precursor ALL;R/R Ph+ B-ALL with refractory disease or greater than or equal to 2 relapses and failure of 2 TKIs;Relapsed/refractory Ph-, B-ALL with refractory disease or greater than or equal to 2 relapses
    ECOG Score Requirement Included in Policy: N/A
    Specialty Pharmacy is Required: Not Defined

    Diffuse Large B-Cell Lymphoma:
    Age Requirement: >= 18
    Duration: 3 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of Hematologist;Oncologist
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • Prior Authorization: Acute Lymphoblastic Leukemia:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: <= 25
    Duration: 3 Month(s)

    Diffuse Large B-Cell Lymphoma:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 3 Month(s)