- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Chronic Myelogenous Leukemia:
Documented Diagnosis: Yes
Duration: 1 year(s)
- PA Applies
- May process through Pharmacy or Medical benefit depending on Patient location; Limited access;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- Acute Lymphoblastic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: Payer Specific
Diagnosis Types: 1 of Ph+ ALL;T315I-positive Ph+ ALL
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Y
Chronic Myelogenous Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Quantity Limit: 2 tablets per 1 day(s).
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