- Orally administered anticancer medication.
- Step Therapy: Chronic Lymphocytic Leukemia:
ST Single Generic
- Acute Myeloid Leukemia:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
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
Diagnosis Types: 2 of Comorbidities that preclude the use of intensive induction chemotherapy;in combination with either azacitidine, decitabine, or cytarabine;Newly diagnosed AML where other medical conditions prevent the use of standard chemotherapy;Newly diagnosed with AML and age >= 60;Relapsed/Refractory acute myeloid leukemia
Excludes Coverage in Maintenance Setting: No
Chronic Lymphocytic Leukemia: Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines
Diagnosis Types: 1 of patients with CLL who have received at least one prior therapy;Small Lymphocytic Lymphoma
- Prior Authorization: Documented Diagnosis: Yes
Duration: 12 Month(s)
Reauthorization Required: Yes
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