bosutinib — CareFirst (Caremark)

Initial criteria

• Diagnosis of CML confirmed by detection of the Philadelphia (Ph) chromosome or BCR::ABL gene by cytogenetic and/or molecular testing
• ANY of the following:
• • Member has not received prior therapy with a tyrosine kinase inhibitor (TKI) (e.g., asciminib, dasatinib, imatinib, nilotinib, ponatinib)
• • Member experienced toxicity or intolerance to prior therapy with a TKI
• • Member experienced resistance to prior therapy with a TKI and results of BCR::ABL1 mutation testing are negative for all of the following: T315I, G250E, V299L, and F317L
• • Member has received hematopoietic stem cell transplant (HSCT) for CML and results of BCR::ABL1 mutation testing are negative for all of the following: T315I, G250E, V299L, and F317L

Reauthorization criteria

• Diagnosis of CML confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing
• Authorization of 12 months may be granted when ANY of the following is met:
• • BCR::ABL1 ≤ 10% and no evidence of disease progression or unacceptable toxicity while on the current regimen for members who have been receiving the requested medication for ≥ 6 months
• • Member has received HSCT and there is no evidence of unacceptable toxicity or disease progression while on the current regimen
• Authorization of up to 7 months may be granted when the member has completed < 6 months of therapy with the requested medication

Approval duration

Initial 7 months; Reauthorization up to 12 months