- 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: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 1 of For induction, consolidation or maintenance therapy;Ph+ ALL;Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ ALL) for whom no other kinase inhibitors are indicated;Relapsed/Refractory Ph+ B-cell ALL;T315I-positive 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)
- Quantity Limit: 4 capsules per 1 day(s).
- Quantity Limit: 204 lancets per 30 day(s).
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