Iclusig (ponatinib) — United Healthcare
Chronic Myelogenous/Myeloid Leukemia (CML)
Preferred products
- imatinib mesylate
- Sprycel (dasatinib)
- Tasigna (nilotinib)
Initial criteria
- Diagnosis of chronic myelogenous/myeloid leukemia (CML)
- AND one of the following:
- 1) Both of the following: disease is in the chronic phase AND patient with resistance or intolerance to two or more tyrosine kinase inhibitor (TKI) therapies [e.g., imatinib mesylate, Sprycel (dasatinib), or Tasigna (nilotinib)]
- OR 2) Confirmed documentation of T315I mutation
- OR 3) Both of the following: disease is in the accelerated or blast phase AND no other kinase inhibitors are indicated
Reauthorization criteria
- Patient does not show evidence of progressive disease while on Iclusig therapy
Approval duration
12 months