Health Net
Tasigna (nilotinib)
Drugs for Cancer : Drugs for Cancer
  • Anti-Cancer:Maximum $200 copayment per State Law. Must use AcariaHealth Specialty Rx.
  • Acute Lymphoblastic Leukemia:
    Duration: 1 plan year
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    Drug Policy Based On: 2 of FDA Approved Indications;NCCN Guidelines
    Diagnosis Types: 2 of All FDA-approved indications;Ph+ ALL;PH+/BCR-ABL+
    ECOG Score Requirement Included in Policy: N/A
    Specialty Pharmacy is Required: Not Defined

    Chronic Myelogenous Leukemia:
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

    Gastrointestinal Stromal Tumor:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: No
    Specialist Type(s): Oncologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year

    Soft Tissue Sarcoma:
    Age Requirement: >= 18
    Duration: 1 plan year
    Specialist Required: Yes
    Specialist Type(s): 1 of Oncologist
    Reauthorization Required: No
    Medical Test Required: No
    Duration of Reauthorization: = 1 plan year
    Drug Policy Based On: 1 of ACCC;AHFS Guidelines;Clinical Pharmacology;Elsevier/Gold Standard Clinical Pharmacology;FDA Approved Indications;Micromedex;NCCN Guidelines;United States Pharmacopeia (USP);Wolters Kluwer Lexi-Drugs
    Diagnosis Types: 1 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: No

  • Step Therapy: ST Single Generic

  • Prior Authorization: Acute Lymphoblastic Leukemia:
    Documented Diagnosis: Yes
    Duration: 1 plan year
    Reauthorization Required: Yes

    Chronic Myelogenous Leukemia:
    Documented Diagnosis: Yes
    Reauthorization Required: Yes

    Gastrointestinal Stromal Tumor:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 1 plan year
    Reauthorization Required: Yes

    Soft Tissue Sarcoma:
    Age Requirement: >= 18
    Duration: 1 plan year