- Prior Authorization: Acute Lymphoblastic Leukemia, Gastrointestinal Stromal Tumor:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
Chronic Myelogenous Leukemia, Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Step Therapy: Chronic Myelogenous Leukemia:
ST Single Brand
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Orally administered anticancer medication.
- Acute Lymphoblastic Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: NCCN Guidelines
Diagnosis Types: Ph+ ALL
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Not Defined
Chronic Myelogenous Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Gastrointestinal Stromal Tumor:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Soft Tissue Sarcoma:
Duration: 12 Month(s)
Reauthorization Required: Yes
Medical Test Required: No
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 1 of All FDA-approved indications;All medically accepted indications;Gastrointestinal stromal tumor (GIST)
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
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