Iclusig — Cigna

Initial criteria

• Patient has newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) AND medication will be used in combination with chemotherapy
• OR patient has acute lymphoblastic leukemia (ALL) and has tried at least one other tyrosine kinase inhibitor (TKI)
• OR patient has acute lymphoblastic leukemia (ALL) with ABL-class translocation
• OR patient has BCR::ABL1-positive chronic myeloid leukemia (CML)
• OR patient has chronic myeloid leukemia (CML) and has tried at least one other tyrosine kinase inhibitor (TKI)

Reauthorization criteria

• Patient continues to derive clinical benefit or has not experienced unacceptable toxicity

Approval duration

12 months