Colorado Rocky Mountain Health Plans Sprycel Prior Auth

Coverage Criteria for Sprycel (dasatinib)

Pediatric authorization

Covered when ALL of the following are met

Pediatric patients <19: Patient is less than 19 years of age

Authorization will be issued for 12 months; prescriptions auto-process without coverage review per policy.

Ph+ CML — Initial

Initial Authorization — Ph+ CML

Adult Ph+ CML: Diagnosis of Philadelphia chromosome-positive or BCR-ABL1-Positive chronic myeloid leukemia

Authorization will be issued for 12 months.

General Reauthorization

Reauthorization — General

Reauthorization requirement: Patient does not show evidence of progressive disease while on Sprycel therapy

Authorization will be issued for 12 months.

Ph+ ALL — Initial

Initial Authorization — Ph+ ALL

Ph+ ALL: Diagnosis of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL)

Authorization will be issued for 12 months.

GIST PDGFRA exon18 — Initial

Initial Authorization — GIST with PDGFRA exon 18 mutation

GIST PDGFRA exon18: Diagnosis of gastrointestinal stromal tumor (GIST)

Mutation status: Tumor is PDGFRA exon 18 mutation positive that is insensitive to imatinib

Prior therapy: Patient has previously received Ayvakit (avapritinib)

Surgical/clinical context: One of: gross residual disease (R2 resection); unresectable primary disease; preoperative/intraoperative tumor rupture; recurrent/metastatic disease with progression

Authorization will be issued for 12 months.

Metastatic chondrosarcoma — Initial

Initial Authorization — Metastatic chondrosarcoma

Metastatic chondrosarcoma: Diagnosis of metastatic chondrosarcoma

Authorization will be issued for 12 months.

Recurrent chordoma — Initial

Initial Authorization — Recurrent chordoma

Recurrent chordoma: Diagnosis of recurrent chordoma

Authorization will be issued for 12 months.

Neoplasms with eosinophilia and ABL1 rearrangement — Initial

Initial Authorization — Neoplasms with eosinophilia

Lineage neoplasm with eosinophilia: Diagnosis of lymphoid, myeloid, or mixed lineage neoplasms with eosinophilia

ABL1 rearrangement: Patient has an ABL1 rearrangement

Authorization will be issued for 12 months.

KIT-mutant cutaneous melanoma — Initial, subsequent-line use

Initial Authorization — KIT-mutant cutaneous melanoma

Cutaneous melanoma diagnosis: Diagnosis of cutaneous melanoma

Metastatic or unresectable: Tumors are metastatic or unresectable

KIT activating mutation: Contains activating mutations of KIT

Line of therapy: Used as second-line or subsequent therapy for disease progression, intolerance, and/or projected risk of progression with BRAF-targeted therapy

Authorization will be issued for 12 months.

Reauthorization

Reauthorization is approved when the following condition is met:

Reauthorization: Patient does not show evidence of progressive disease while on Sprycel therapy.

Authorization will be issued for 12 months if met.

Second-line or subsequent therapy

Coverage may be provided for second-line or subsequent therapy in specified circumstances:

Second-line use: Used as second-line or subsequent therapy for disease progression, intolerance, and/or projected risk of progression with BRAF-targeted therapy.

Authorization will be issued for 12 months.

NCCN Recommended Regimens

Covered when recognized by NCCN:

NCCN recommended regimens: The drug has been recognized for treatment of the cancer indication by the NCCN Drugs and Biologics Compendium with a Category of Evidence and Consensus of 1, 2A, or 2B.

Coverage criteria in this document may be superseded where applicable state mandates or compendia requirements apply. Some states mandate benefit coverage for off‑label medication uses or require use of alternative compendium references; where such mandates exist, they take precedence over the language in this policy.

Authorization decisions and duration may be affected by external requirements. Authorization will be issued for 12 months when criteria are met, but state mandates, federal regulatory requirements, and the member-specific benefit plan may modify coverage determinations. Other policies and utilization management programs may also apply and influence approvals.

Regimen / Indication	NCCN Category	Coverage status
Regimens recognized by the NCCN Drugs and Biologics Compendium for the drug's approved or recommended cancer indications
Regimens recognized by the NCCN Drugs and Biologics Compendium for select off-label or specialty tumor uses (e.g., KIT‑mutant melanoma, GIST with PDGFRA exon 18) when listed with Category 1, 2A, or 2B

Provider Actions, Documentation, and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization required for adults; pediatric auto-process — initial auth issued for 12 months when criteria met.

Note

Authorization Duration

Prior authorization duration — Authorization will be issued for 12 months when criteria are met.

Documentation Required

GIST Prior Therapy Requirement

GIST prior therapy requirement — For PDGFRA exon 18 mutation insensitive to imatinib, prior Ayvakit (avapritinib) required.

Diagnosis: gastrointestinal stromal tumor (GIST)

Line of Therapy Specifications

first-line

Newly diagnosed Ph+ CML: Sprycel indicated for newly diagnosed adults with Ph+ CML in chronic phase

second-line

Subsequent-line KIT-mutant melanoma: Use as second-line or subsequent therapy for disease progression, intolerance, and/or projected risk of progression with BRAF-targeted therapy

second-line

Second-line or subsequent: Used as second-line or subsequent therapy for disease progression, intolerance, and/or projected risk of progression with BRAF-targeted therapy.

Authorization will be issued for 12 months.

Biomarker and Diagnostic Requirements

PDGFRA exon 18 — mutation positive and insensitive to imatinib

BiomarkerPDGFRA exon 18 mutation positive

Therapeutic sensitivityTumor is insensitive to imatinib

Prior therapy requirementPatient has previously received Ayvakit (avapritinib)

Authorization durationAuthorization will be issued for 12 months when criteria are met

ABL1 rearrangement — required for neoplasms with eosinophilia

BiomarkerABL1 rearrangement

Required diagnosis context

Key Definitions

Ph+ definition — Philadelphia chromosome-positive / BCR-ABL1-positive

DefinitionPhiladelphia chromosome-positive (Ph+) or BCR-ABL1-positive disease

Applies toChronic myeloid leukemia (CML) and acute lymphoblastic leukemia (ALL) indications

Clinical noteSprycel indicated for Ph+ CML newly diagnosed adults and Ph+ ALL with resistance or intolerance to prior therapy

NCCN Recommended Regimens definition — Regimens recognized with Category 1/2A/2B

DefinitionRegimens recognized by the NCCN Drugs and Biologics Compendium with Category 1, 2A, or 2B evidence and consensus

Coverage implicationDrug/regimen must be listed in NCCN Drugs & Biologics Compendium with Category 1, 2A, or 2B to meet this criterion

Background

Dasatinib (Sprycel) is a tyrosine kinase inhibitor approved for treatment of Philadelphia chromosome‑positive (Ph+) chronic myeloid leukemia (CML) and Ph+ acute lymphoblastic leukemia (ALL) in adults; it is also indicated in pediatric patients for Ph+ CML and Ph+ ALL in combination with chemotherapy. The agent is used both in newly diagnosed Ph+ CML in chronic phase and for Ph+ CML or Ph+ ALL in patients with resistance or intolerance to prior therapy. In addition to these labeled indications, expert compendia such as the NCCN list certain off‑label and specialty tumor uses that may be considered under defined criteria.

Covered Regimens and Recognition

Regimen / NCCN listing	Required evidence category	Coverage implication
Any regimen for the drug that is recognized in the NCCN Drugs and Biologics Compendium for the relevant cancer indication
Recognition requires a Category of Evidence and Consensus of 1, 2A, or 2B in the NCCN Compendium
When the regimen is so recognized, coverage is provided per policy (authorization issued for 12 months when other criteria are met)

Revision History

2026-01-01policy_effectiveLatest

Policy effective date set to 2026-01-01 with standard authorization provisions applied.

2025-10-25policy_review

Policy underwent last review on 2025-10-25.

2025-10-01next_review_due

OpenPayer

Sprycel (dasatinib) prior authorization and coverage criteria

Coverage Criteria for Sprycel (dasatinib)

Provider Actions, Documentation, and Operational Notes

Line of Therapy Specifications

Biomarker and Diagnostic Requirements

Key Definitions

Background

Covered Regimens and Recognition

Revision History