UnitedHealthcare
Bosulif (bosutinib)
Drugs for Cancer : Drugs for Cancer
  • Acute Lymphoblastic 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
    Diagnosis Types: Ph+ ALL
    ECOG Score Requirement Included in Policy: N/A
    Specialty Pharmacy is Required: Not Defined

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

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

    Chronic Myelogenous Leukemia:
    Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Quantity Limit: limit maximum 1 EA PER 1 day(s)
  • Orally administered anticancer medication.
  • Step Therapy: Chronic Myelogenous Leukemia:
    ST Single Brand