Iclusig (ponatinib) — CareFirst (Caremark)

Initial criteria

• Diagnosis of CML confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing
• Member has T315I-positive CML OR
• Member has CML with no identifiable BCR::ABL1 mutations and resistance to primary therapy with bosutinib, dasatinib, or nilotinib OR
• Member has chronic phase (CP) CML with resistance or intolerance to at least two prior kinase inhibitors (e.g., bosutinib, dasatinib, imatinib, nilotinib) OR
• Member has accelerated phase (AP) or blast phase (BP) CML and treatment with any other kinase inhibitors (e.g., bosutinib, dasatinib, imatinib, nilotinib) is not indicated

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on current regimen AND
• CML confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing OR
• Member has received HSCT for CML

Approval duration

12 months