Iclusig (ponatinib) — CareFirst (Caremark)
Philadelphia chromosome positive (Ph+) Acute Lymphoblastic Leukemia (ALL) / Lymphoblastic Lymphoma (LL)
Initial criteria
- Ph+ ALL/LL confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing
Reauthorization criteria
- No evidence of unacceptable toxicity or disease progression while on current regimen AND
- Ph+ ALL/LL confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing OR
- Member has received HSCT for ALL/LL
Approval duration
12 months