CurrentCignaPolicy N/A

Oncology - Dasatinib Preferred Specialty Management Policy (Sprycel vs generic dasatinib)

Defines Cigna's preferred specialty management program requiring use of generic dasatinib tablets as the preferred product and criteria to authorize the non-preferred brand product Sprycel for patients meeting exception criteria; applies to health benefit plans administered by Cigna companies.

Policy Summary

PayerCigna

PolicyOncology - Dasatinib Preferred Specialty Management Policy (Sprycel vs generic dasatinib)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2025

Next Review DateN/A

Key ActionWhen requesting Sprycel, document prior use of generic dasatinib and prescriber rationale that a formulation difference would cause a significant allergy or serious adverse reaction.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearapproval duration (Sprycel)

01/01/2025effective

10/02/2024last review

Coverage Criteria for Dasatinib (Sprycel vs Generic)

Sprycel Exception Criteria

Non-Preferred Product Exception Criteria (Sprycel): Approve for 1 year if the patient meets ALL of the following (A, B, and C):

Sprycel exception (A,B,C): A) Patient meets the standard Oncology - Dasatinib Prior Authorization Policy criteria; AND B) Patient has tried generic dasatinib tablets [documentation required]; AND C) Patient cannot continue to use the Preferred medication due to a formulation difference in the inactive ingredient(s) (e.g., difference in dyes, fillers, preservatives) which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required].

Approval duration: 1 year.

Preferred product authorization when exceptions not met

Fallback if exception criteria not met:

Fallback: For a patient who has met the Oncology - Dasatinib Prior Authorization Policy criteria, but has not met exception criteria (1B) and (1C) for brand Sprycel: approve generic dasatinib tablets.

Policy Summary

PayerCigna

PolicyOncology - Dasatinib Preferred Specialty Management Policy (Sprycel vs generic dasatinib)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01/01/2025

Next Review DateN/A

Key ActionWhen requesting Sprycel, document prior use of generic dasatinib and prescriber rationale that a formulation difference would cause a significant allergy or serious adverse reaction.

SourceLink

On This Page

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Provider Requirements and Operational Rules

Prior Authorization

Prior Authorization Required

All medications (preferred and non-preferred) require meeting the standard Oncology - Dasatinib Prior Authorization Policy criteria. Requests for the non-preferred product (Sprycel) will be reviewed using the non-preferred product exception criteria. If the patient meets the standard Oncology - Dasatinib Prior Authorization Policy criteria but has not tried the preferred product, approval for the preferred product (generic dasatinib tablets) will be authorized.

Preferred product: generic dasatinib tablets
Non-preferred product: Sprycel

Step Therapy

Step Therapy / Try Preferred Product First

Program requires patients to try the preferred product (generic dasatinib tablets) prior to approval of the non-preferred product (Sprycel). If the patient meets the Oncology - Dasatinib Prior Authorization Policy criteria but has not tried the preferred product, authorization will be for the preferred product instead of the non-preferred product.

Step therapy: Patient must trial generic dasatinib tablets before Sprycel will be approved
Approval for Sprycel requires meeting the non-preferred product exception criteria

Documentation Required

Documentation Requirements

Documentation is required where noted in the criteria. Documentation may include chart notes, prescription claims records, and prescription receipts to support prior use of the preferred product and any clinical rationale for switching due to formulation differences or adverse reactions.

Documentation required to show trial of generic dasatinib tablets
Documentation required to support inability to use preferred medication due to formulation differences or significant allergy/serious adverse reaction

Denial Risk

Denial for Failure to Meet Exception Criteria

Requests for Sprycel that do not meet the non-preferred product exception criteria are considered not medically necessary and will be denied. If a patient meets the Oncology - Dasatinib Prior Authorization Policy criteria but not the exception criteria for Sprycel (including lack of documented trial of generic dasatinib tablets or lack of documentation of a formulation-related allergy/serious adverse reaction), approval will be for generic dasatinib tablets instead.

Denial if exception criteria (trial of preferred product and documented formulation-related inability to use preferred product) are not met
Sprycel approval: Approve up to 1 year if all exception criteria are met (A, B, and C)

Background

Dasatinib is a tyrosine kinase inhibitor indicated for Philadelphia chromosome–positive acute lymphoblastic leukemia (Ph+ ALL) and Philadelphia chromosome–positive chronic myeloid leukemia (Ph+ CML) in specified phases and age groups. This policy distinguishes the preferred product (generic dasatinib tablets) from the non-preferred brand (Sprycel) and establishes authorization rules: Sprycel may be approved for 1 year only when the patient meets all elements of the non-preferred product exception criteria, including meeting the standard Oncology - Dasatinib Prior Authorization Policy criteria, documented trial of generic dasatinib tablets, and prescriber-documented inability to continue the preferred medication due to an inactive-ingredient formulation difference that would cause a significant allergy or serious adverse reaction. If the patient meets the Oncology - Dasatinib prior authorization criteria but does not meet the Sprycel exception criteria B and C, the policy directs approval of the generic dasatinib tablets instead.

OpenPayer

Oncology - Dasatinib Preferred Specialty Management Policy (Sprycel vs generic dasatinib)

Coverage Criteria for Dasatinib (Sprycel vs Generic)

Provider Requirements and Operational Rules

Background

Definitions