COVERED USES:

FDA Approved Indications:

• Adults with chronic, accelerated, or myeloid or lymphoid blast phase chronic myeloid leukemia (CML) (205.1_) with resistance or intolerance to prior therapy including Gleevec®.
• Adults with Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) (204.0_) with resistance or intolerance to prior therapy

All FDA-approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

Must be prescribed by an Oncologist.

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

The condition being treated meets the "Covered Uses" criteria above.

For all indications, documentation of response to Sprycel® must be submitted in order for continued authorization.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to six months.