Phyrago — CareFirst (Caremark)

Initial criteria

• The member has one of the following: Ph+ ALL/LL confirmed by detection of the Philadelphia chromosome or BCR::ABL gene by cytogenetic and/or molecular testing; Ph-like B-ALL/LL with ABL-class kinase fusion confirmed by testing; T-cell ALL/LL with ABL-class translocation confirmed by testing and disease is relapsed or refractory
• Member has not received prior therapy with a TKI (e.g., bosutinib, imatinib, nilotinib, ponatinib) OR experienced toxicity or intolerance to a prior TKI OR experienced resistance to a prior TKI and BCR::ABL1 mutational testing is negative for T315I/A, F317L/V/I/C, and V299L
• OR member has received HSCT for Ph+ ALL/LL and BCR::ABL1 mutational testing is negative for T315I/A, F317L/V/I/C, and V299L

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on current regimen
• Member continues to meet one of the following: Ph+ ALL/LL confirmed by cytogenetic and/or molecular testing; Ph-like B-ALL/LL with ABL-class kinase fusion confirmed; T-cell ALL/LL with ABL-class translocation confirmed; or has received HSCT for ALL/LL

Approval duration

Initial and reauthorization: 12 months