Azacitidine (Vidaza)

Approved for:

Office administration

Indications for Prior Authorization

  • myelodysplastic syndrome (MDS)
    • refractory anemia
    • chronic myelomonocytic leukemia
  • acute myeloid leukemia (AML)

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee.

  • beta-thalassemia
  • chronic myelogenous leukemia (CML)
  • solid tumors
  • any other diagnosis not listed in the approved indications

All of the following must be met:

  • refractory anemia
    • failure or significant side effects to treatment with epoetin alpha
  • acute myeloid leukemia
    • Diagnosis of untreated acute myelogenous leukemia (AML) in elderly patients (>60 years old) who are not considered eligible to receive conventional induction therapy.

Dosing

Initial

  • up to 75 mg/m2 SubQ or IV for 7 days q 4 weeks for two treatment cycles

Maintenance

  • up to 100 mg/m2 SubQ or IV for 7 days, repeat q 4 weeks

The drug is approvable for coverage for 6 months.


Western Health Advantage Pharmacy and Therapeutics Committee

Approved:  November 2011 | Revised: July 2015

Last review date: July 20, 2016