bosutinib — CareFirst (Caremark)

Initial criteria

• Diagnosis of Ph+ B-ALL or Ph+ B-LL confirmed by detection of 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., dasatinib, imatinib, nilotinib, ponatinib)
• • Member experienced intolerance or toxicity 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 HSCT for Ph+ B-ALL/LL and results of BCR::ABL1 mutation testing are negative for all of the following: T315I, G250E, V299L, and F317L

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on the current regimen
• AND either:
• • Ph+ B-ALL/LL confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing, OR
• • Member has received HSCT for B-ALL/LL

Approval duration

Initial 12 months; Reauthorization 12 months