Health Net
Iclusig (ponatinib)
Drugs for Cancer : Drugs for Cancer
  • Quantity Limits Apply
  • Prior Authorization: Acute Lymphoblastic Leukemia:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 1 plan year
    Reauthorization Required: Yes

    Chronic Myelogenous Leukemia:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

  • Limited Access. Must use AcariaHealth Specialty Rx. Anti-Cancer:Maximum $200 copayment per State Law.
  • Acute Lymphoblastic Leukemia:
    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
    Diagnosis Types: 2 of PH+/BCR-ABL+;Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ ALL) for whom no other kinase inhibitors are indicated;T315I-positive Ph+ ALL
    ECOG Score Requirement Included in Policy: N/A
    Specialty Pharmacy is Required: Not Defined

    Chronic Myelogenous Leukemia:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Hematologist;Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year