Self administration- Oral
Indications for Prior Authorization
- Treatment of adult patients with chronic, accelerated, or blast phase chronic myeloid leukemia (CML)
- Treatment of adult patients with Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL)
Patients must meet the following criteria for the indication(s) above.
Patient is resistant or intolerant to prior tyrosine kinase inhibitor therapy
- CML: Gleevec, Sprycel, Tasigna and Bosulif
- Ph+ ALL: Gleevec and Sprycel
For ALL, patients must undergo genetic testing to confirm Ph+ status
Patient must not be pregnant or planning on becoming pregnant
The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee.
- All non-FDA approved uses not listed in the approved indications
- 45 mg orally once a day
One year or until disease progression or intolerable side effects
- Box warnings for: arterial/venous thrombosis, hepatotoxicity, congestive heart failure, pancreatitis, cardiac arrhythmias and myelosuppression.
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: March 2013 Reviewed: December 2013