Imkeldi — CareFirst (Caremark)
Acute Lymphoblastic Leukemia (ALL)
Preferred products
- Gleevec
- imatinib mesylate
Initial criteria
- Ph+ ALL/LL confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing OR
- T-cell ALL/LL with ABL-class translocation confirmed by cytogenetic and/or molecular testing with relapsed or refractory disease OR
- Member has received HSCT for Ph+ ALL/LL
Reauthorization criteria
- No evidence of unacceptable toxicity or disease progression while on current regimen
- Ph+ ALL/LL confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing OR T-cell ALL/LL with ABL-class translocation confirmed OR member has received HSCT for ALL/LL
Approval duration
12 months