- Prior Authorization: Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
- Acute Myeloid Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
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: IDH1 mutation
Diagnosis Types: 1 of Comorbidities that preclude the use of intensive induction chemotherapy;IDH1 mutation as detected by FDA approved test;Medically accepted uses supported by NCCN Category 1, 2A or 2B level of evidence;Newly diagnosed with AML and age >= 60;Post induction therapy;Relapsed/Refractory acute myeloid leukemia
Excludes Coverage in Maintenance Setting: No
Cholangiocarcinoma:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Orally administered anticancer medication.
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