- Acute Lymphoblastic Leukemia:
Age Requirement: >= 18
Duration: 3 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: FDA Approved Indications
Diagnosis Types: 2 of First relapse following a remission lasting less than 12 months;Primary refractory disease;Relapsed or refractory B-cell ALL;Relapsed or refractory disease after 2 or more lines of systemic therapy;Relapsed or refractory disease at least 100 days after allogenic stem cell transplantation (HSCT);Relapsed/refractory Ph+ B-cell ALL that is refractory to 2 TKIs
ECOG Score Requirement Included in Policy: N/A
Contraindications: CNS disorders
Specialty Pharmacy is Required: Not Defined
- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
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