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Iclusig (ponatinib) — United Healthcare

Myeloid/Lymphoid or Mixed Lineage Neoplasms with Eosinophilia

Initial criteria

  • Diagnosis of lymphoid, myeloid, or mixed lineage neoplasms with eosinophilia
  • AND one of the following: patient has a FGFR1 rearrangement OR patient has an ABL1 rearrangement

Reauthorization criteria

  • Patient does not show evidence of progressive disease while on Iclusig therapy

Approval duration

12 months