Skip to content
The Policy VaultThe Policy Vault

Bosulif (bosutinib) — Highmark

Philadelphia chromosome-positive (Ph+) chronic myelogenous leukemia (CML)

Initial criteria

  • age ≥ 18 years AND (newly-diagnosed Ph+ CML in chronic phase (ICD-10: C92.1) OR Ph+ CML (ICD-10: C92.1) in chronic, accelerated, or blast phase with resistance or intolerance to one prior therapy (for example, imatinib, Sprycel, Tasigna, etc.))
  • If request is for Bosulif oral capsules: request is for Bosulif 100 mg oral capsules AND member has an inability to swallow oral tablets
  • OR age ≥ 1 year AND diagnosis of Ph+ CML (ICD-10: C92.1) in chronic phase AND (newly-diagnosed OR resistance or intolerance to one prior therapy (for example, imatinib, Sprycel, Tasigna, etc.)) AND if request is for Bosulif 100 mg oral capsules: member has an inability to swallow oral tablets