- PA Applies
- Acute Lymphoblastic Leukemia:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: NCCN Guidelines
Diagnosis Types: 2 of F317L/V/I/C, T315A, or V299L mutation;For induction, consolidation or maintenance therapy;Ph+ ALL;Relapsed/Refractory Ph+ B-cell ALL;Use post-hematopoietic stem cell transplant
ECOG Score Requirement Included in Policy: N/A
Specialty Pharmacy is Required: Not Defined
Chronic Myelogenous Leukemia: Age Requirement: >= 1
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Gastrointestinal Stromal Tumor: Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): Accredo Health Group, Inc.
Reauthorization Required: No
Duration of Reauthorization: N/A
Soft Tissue Sarcoma: Duration: 1 year(s)
Reauthorization Required: No
Medical Test Required: No
Duration of Reauthorization: N/A
Drug Policy Based On: 1 of Clinical Pharmacology;FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 2 of Gastrointestinal stromal tumor (GIST);Soft tissue sarcoma
Physician attestation of diagnostic or lab test required: No
ECOG Score Requirement Included in Policy: N/A
Documented Diagnosis: Yes
- Prior Authorization: Acute Lymphoblastic Leukemia:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Chronic Myelogenous Leukemia: Documented Diagnosis: Yes
Age Requirement: >= 1
Duration: 1 year(s)
Gastrointestinal Stromal Tumor, Soft Tissue Sarcoma: Documented Diagnosis: Yes
Duration: 1 year(s)
- Quantity Limit: 4 capsules per 1 day(s).
- Step Therapy: Gastrointestinal Stromal Tumor:
ST Single Generic
- Available only through Specialty Pharmacy; May process through Pharmacy or Medical benefit depending on Patient location;
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;
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