Sutter Health Plus
Kisqali (400 MG Dose) (ribociclib)
Drugs for Cancer : Drugs for Cancer
  • Step Therapy: Diabetes Type 2: SGLT2 + Combo:
    ST Single Generic

  • ST_APPLIES
  • QL (2 per Rx);
  • Acute Lymphoblastic Leukemia:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: Payer Specific
    Diagnosis Types: 2 of as a single agent;CD19+ B-cell precursor ALL;First or second complete remission B-cell precursor type. MRD is greater than or equal to 0.1%;R/R CD19+ B-cell precursor ALL
    ECOG Score Requirement Included in Policy: N/A
    Contraindications: Active CNS malignancy involvement
    Specialty Pharmacy is Required: Y

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