- Acute Myeloid Leukemia:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: FDA Approved Indications
Supporting Documentation Requirements: 2 of Chart Notes;Documented rationale showing inability to use IV or SQ formulation
Quantity Limit: N/A
Criteria for Reauthorization: Member is responding positively to therapy
Diagnosis Types: 2 of Acute myeloid leukemia;Single agent use;Treatment after complete remission with incomplete blood count recovery (CRi) following intensive induction chemotherapy;Treatment after first complete remission (CR) following intensive induction chemotherapy
Excludes Coverage in Maintenance Setting: No
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Anti-Cancer: Maximum $200 copayment per State Law.
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