Xospata (gilteritinib) — CareFirst (Caremark)

FLT3 mutation-positive AML as maintenance therapy post-allogeneic hematopoietic cell transplantation

Initial criteria

Medical record documentation of FLT3 and IDH1 mutation status, where applicable
For FLT3 mutation-positive AML without IDH1 mutation, Xospata may be used as a single agent or in combination with azacitidine in any of the following: induction therapy if not a candidate for or declines intensive induction therapy; post-induction therapy when there is response to Xospata therapy
For FLT3 mutation-positive AML, Xospata may be used as a single agent in any of the following: maintenance therapy post-allogeneic hematopoietic cell transplantation; relapsed or refractory disease
For myeloid and/or lymphoid neoplasms with eosinophilia with FLT3 rearrangement, Xospata may be used in chronic phase or blast phase

Member continues treatment for an indication listed in the coverage criteria
No evidence of unacceptable toxicity or disease progression while on Xospata therapy

12 months