- Acute Myeloid Leukemia:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Hematologist;Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Drug Policy Based On: 1 of FDA Approved Indications;NCCN Guidelines;Payer Specific
Supporting Documentation Requirements: Chart Notes
Quantity Limit: N/A
Criteria for Reauthorization: Member is responding positively to therapy
Diagnosis Types: 2 of Newly diagnosed AML and age >=75;Newly diagnosed AML and unable to tolerate intensive therapy;Newly diagnosed AML in combination with low-dose cytarabine;Relapsed or refractory disease (in relapse later than 12 months) after initial successful induction regimen
Excludes Coverage in Maintenance Setting: No
- Prior Authorization: Acute Myeloid Leukemia:
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 12 Month(s)
Reauthorization Required: Yes
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