Leukine (sargramostim) — CareFirst (Caremark)
High-risk neuroblastoma
Initial criteria
- Authorization may be granted when Leukine is used with one of the following regimens:
- Dinutuximab (Unituxin) and isotretinoin (13-cis-retinoic acid).
- Temozolomide, irinotecan, and dinutuximab (Unituxin).
- Naxitamab-gqgk (Danyelza).
Reauthorization criteria
- Member must continue to meet all requirements in the coverage criteria.
Approval duration
6 months