imatinib mesylate — CareFirst (Caremark)

Initial criteria

• Diagnosis of CML confirmed by detection of the Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing
• Member did not fail (other than due to intolerance) prior therapy with a tyrosine kinase inhibitor (TKI) such as asciminib, dasatinib, nilotinib, bosutinib, or ponatinib

Reauthorization criteria

• For members receiving the requested medication for 6 months or greater: BCR::ABL1 ≤ 10% and no evidence of disease progression or unacceptable toxicity
• For members who have received hematopoietic stem cell transplant (HSCT): no evidence of disease progression or unacceptable toxicity
• If completion of less than 6 months of therapy: continue up to 7 months if no evidence of progression or unacceptable toxicity

Approval duration

Initial: 7 months; Reauthorization: up to 12 months