Iclusig (ponatinib tablets) — Cigna
Acute Lymphoblastic Leukemia (ALL)
Initial criteria
- Approve for 1 year if the patient meets BOTH of the following (A and B):
- A) Patient meets ONE of the following (i or ii):
- i. Patient has Philadelphia chromosome-positive acute lymphoblastic leukemia; OR
- ii. Patient has ABL-class translocation; AND
- B) Patient meets ONE of the following (i, ii, or iii):
- i. The medication will be used in combination with chemotherapy; OR
- ii. The acute lymphoblastic leukemia is T315I-positive; OR
- iii. Patient has tried at least one other tyrosine kinase inhibitor.
Approval duration
1 year