Scemblix (asciminib) — CareFirst (Caremark)

Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase (Ph+ CML-CP) with the T315I mutation

Initial criteria

For CML: Member has newly diagnosed Ph+ CML in chronic phase and the requested medication will be used as a single agent OR
Member has T315I mutation positive CML in chronic phase and results of BCR::ABL1 mutation testing are negative for A337T, P465S, M244V, and F359V/I/C mutations OR
Member has previously treated CML in chronic phase that has not tested positive for A337T, P465S, M244V, and F359V/I/C mutations OR
Member has CML in accelerated phase, has not tested positive for A337T, P465S, M244V, and F359V/I/C mutations, and the requested medication will be used as a single agent OR
Member has myeloid and/or lymphoid neoplasms with eosinophilia and ABL1 rearrangement in chronic or blast phase

Member is requesting reauthorization for an indication listed in the coverage criteria section AND
There is no evidence of unacceptable toxicity or disease progression while on the current regimen

12 months