- 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
- Orally administered anticancer medication.
- 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: 1 of For induction, consolidation or maintenance therapy;Ph+ ALL;Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ ALL) for whom no other kinase inhibitors are indicated;Relapsed/Refractory Ph+ B-cell ALL;T315I-positive 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)
- Quantity Limit: limit maximum 1 EA PER 1 day(s)
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