COVERED USES:

FDA Approved Indications:

• Sprycel® is indicated for treatment of 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®.
• Sprycel® is indicated for the treatment of adults with Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) (204.0_) with resistance or intolerance to prior therapy including Gleevec®.

Requests for a non-FDA approved ("off-label") indication requires the proposed indication be listed in either the American Hospital Formulary System (AHFS), USP-DI, or Drugdex and is considered subject to evaluation of the prescriber's medical rationale, formulary alternatives, the available published evidence-based research and whether the proposed use is determined to be experimental/investigational.

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:

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 for up to six months.