UnitedHealthcare
Mylotarg (gemtuzumab ozogamicin)
Drugs for Cancer : Drugs for Cancer
  • Acute Myeloid Leukemia:
    Duration: 12 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): 1 of Hematologist;Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
    Quantity Limit: N/A
    Criteria for Reauthorization: No evidence of disease progression or unacceptable toxicity
    Use of Biomarkers in Policy: CD33 mutation
    Diagnosis Types: 3 of CD33-positive acute myeloid leukemia;Newly diagnosed acute myeloid leukemia;Relapsed/Refractory acute myeloid leukemia
    Excludes Coverage in Maintenance Setting: No

  • Prior Authorization: Acute Myeloid Leukemia:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes