Sutter Health Plus
Victoza (liraglutide)
Hormones : Drugs for Diabetes
  • 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).