Gleevec — CareFirst (Caremark)

Initial criteria

• Any of the following:
• Member has Ph+ ALL/LL confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing OR
• Member has T-cell ALL/LL with ABL-class translocation confirmed by cytogenetic and/or molecular testing and disease is relapsed or refractory OR
• Member has received HSCT for Ph+ ALL/LL

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on current regimen AND any of the following:
• Ph+ ALL/LL confirmed by detection of Ph chromosome or BCR::ABL gene OR
• T-cell ALL/LL with ABL-class translocation confirmed by cytogenetic and/or molecular testing OR
• Member has received HSCT for ALL/LL

Approval duration

Initial: 12 months; Reauth: 12 months