- Anti-Cancer: Maximum $200 copayment per State Law.
- Acute Myeloid Leukemia:
Age Requirement: >= 18
Duration: 12 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: = 1 plan year
Drug Policy Based On: FDA Approved Indications
Supporting Documentation Requirements: 2 of Chart Notes;FLT3 Mutation Evidence
Quantity Limit: N/A
Criteria for Reauthorization: Member is responding positively to therapy
Use of Biomarkers in Policy: FLT3 mutation
Diagnosis Types: 2 of FLT3 mutation-positive AML detected by FDA-approved test;Relapsed/Refractory acute myeloid leukemia
Excludes Coverage in Maintenance Setting: No
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
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