Gleevec — CareFirst (Caremark)
Acute Lymphoblastic Leukemia (ALL) or Lymphoblastic Lymphoma (LL)
Initial criteria
- 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
- Member has Ph+ ALL/LL confirmed by cytogenetic and/or molecular testing OR
- Member has 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
12 months