Bosulif (bosutinib)
Indications for Prior Authorization
Bosulif (bosutinib)
-
For diagnosis of Accelerated or Blast Phase Chronic Myelogenous/Myeloid Leukemia
Indicated for the treatment of adult patients with accelerated or blast phase Philadelphia chromosome-positive (Ph+) chronic myelogenous leukemia (CML) with resistance or intolerance to prior therapy. -
For diagnosis of Chronic Phase Chronic Myelogenous Leukemia
Indicated for the treatment of adult and pediatric patients 1 year of age and older with chronic phase (CP) Philadelphia chromosome-positive chronic myelogenous leukemia (Ph+ CML), newly-diagnosed or resistant or intolerant to prior therapy.
Criteria
Bosulif
Prior Authorization (Initial Authorization)
Length of Approval: 12 Month(s)
- Diagnosis of Philadelphia chromosome-positive chronic myelogenous/myeloid leukemia (Ph+ CML) [1, 2] AND
- One of the following:
- Disease is in the accelerated or blast phase OR
- Both of the following:
- Both of the following:
- Disease is in the chronic phase
- Patient is 1 year of age or older
- One of the following:
- Trial and failure, contraindication, or intolerance to BOTH of the following:
- generic dasatinib
- generic imatinib
- Continuation of prior therapy
Bosulif
Prior Authorization (Reauthorization)
Length of Approval: 12 Month(s)
- Patient does not show evidence of progressive disease while on therapy
P & T Revisions
2025-03-10, 2024-11-07, 2024-06-05, 2024-01-31, 2023-11-29, 2023-07-05, 2023-03-20, 2022-03-28, 2021-09-27, 2021-05-20, 2021-05-03, 2019-11-04
References
- Bosulif Prescribing Information. Pfizer. New York, NY. December 2024.
- National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology: Chronic Myeloid Leukemia. V.3.2025. https://www.nccn.org/professionals/physician_gls/pdf/cml.pdf. Accessed February 2025.
Revision History
- 2025-03-10: Annual Review. Criteria updates included removing step requirement w/COT bypass in reauth criteria per policy. Updated references.
- 2024-11-07: Updated trial and failure requirement
- 2024-06-05: Annual Review - No criteria changes
- 2024-01-31: Addition of new 50 and 100mg capsules
- 2023-11-29: Guideline update due to expanded indication
- 2023-07-05: Removed specialist requirement
- 2023-03-20: Annual Review - no criteria changes
- 2022-03-28: Annual review - no changes to criteria
- 2021-09-27: Addition of EHB formulary to guideline, no changes to criteria
- 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
- 2021-05-03: Updated GPIs
- 2019-11-04: Added embedded step through generic imatinib for Brand Bosulif and allow current users to bypass the step per form strategy update
HEALTHY LIVING