- 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
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