glasdegib — CareFirst (Caremark)

Initial criteria

• The requested medication is used in combination with low-dose cytarabine
• Member is age ≥ 75 years OR has comorbidities that preclude treatment with intensive induction chemotherapy OR declines intensive induction chemotherapy
• The requested medication will be used in one of the following clinical settings: treatment for induction therapy for AML without IDH1 mutation OR post-induction/consolidation therapy following response to previous therapy with the same regimen

Reauthorization criteria

• Member is requesting reauthorization for an indication listed in the Coverage Criteria section
• There is no evidence of disease progression or unacceptable toxicity while on the current regimen

Approval duration

12 months