- Limited Access; Anti-Cancer: Maximum $200 copayment per State Law.
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
- Acute Myeloid Leukemia:
Age Requirement: >= 18
Duration: 12 Month(s)
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: FDA Approved Indications
Supporting Documentation Requirements: 3 of Chart Notes;IDH2 Mutation Evidence;Lab Tests
Quantity Limit: N/A
Criteria for Reauthorization: Member is responding positively to therapy
Use of Biomarkers in Policy: IDH2 mutation
Diagnosis Types: 1 of >=60 years and not a candidate for intensive remission induction therapy;Relapsed or refractory AML with an IDH2 mutation as detected by an FDA-approved test;Single agent use
Excludes Coverage in Maintenance Setting: No
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