Tasigna — CareFirst (Caremark)

Initial criteria

• Diagnosis of Ph+ ALL or Ph+ LL confirmed by detection of the Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing
• Member has not received prior therapy with a TKI (e.g., bosutinib, dasatinib, imatinib, ponatinib) OR member experienced toxicity or intolerance to prior TKI therapy OR member experienced resistance to prior TKI therapy and BCR::ABL1 mutational testing is negative for T315I, Y253H, E255K/V, F359V/C/I, and G250E OR member has received HSCT for Ph+ ALL/LL and BCR::ABL1 mutational testing is negative for T315I, Y253H, E255K/V, F359V/C/I, and G250E

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on the current regimen
• Diagnosis of Ph+ ALL/LL confirmed by detection of Ph chromosome or BCR::ABL gene by cytogenetic and/or molecular testing OR member has received HSCT for ALL/LL

Approval duration

Initial 12 months; continuation 12 months