| Anthem Blue Cross (HMO, PPO, EPO) |
| carmustine (carmustine) |
| Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: limit maximum 3 EA PER fill retail
- Acute Myeloid Leukemia:
Age Requirement: < 19
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
Supporting Documentation Requirements: FLT3 Mutation Evidence
Quantity Limit: N/A
Criteria for Reauthorization: No evidence of disease progression or unacceptable toxicity
Use of Biomarkers in Policy: FLT3 mutation
Diagnosis Types: 2 of FLT3 mutation-positive AML detected by FDA-approved test;Medically accepted uses supported by NCCN Category 1, 2A or 2B level of evidence;Relapsed/Refractory acute myeloid leukemia
Excludes Coverage in Maintenance Setting: No
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