Iclusig (ponatinib tablets) — Cigna

Initial criteria

• Approve for 1 year if the patient meets ALL of the following (A, B, and C):
• A) Patient is age ≥ 18 years; AND
• B) Patient meets ONE of the following (i or ii):
• i. Patient has Philadelphia chromosome-positive chronic myeloid leukemia; OR
• ii. Patient has BCR::ABL1-positive chronic myeloid leukemia; AND
• C) Patient meets ONE of the following (i, ii or iii):
• i. The chronic myeloid leukemia is T315I-positive; OR
• ii. Patient has tried at least one other tyrosine kinase inhibitor; OR
• iii. Patient meets BOTH of the following (a and b):
• a) Patient has accelerated-phase CML or blast-phase CML; AND
• b) No other tyrosine kinase inhibitor is indicated.

Approval duration

1 year