Colorado Rocky Mountain Health Plans Iclusig Prior Auth | OpenPayer

Loading...

Colorado Rocky Mountain Health Plans Iclusig Prior Auth | OpenPayer

Patients less than 19 years

Covered when ALL of the following are met for patients <19 years:

Pediatric approval: Patient is less than 19 years of age

Authorization issued for 12 months

CML Initial Authorization

Covered when ALL of the following are met for CML initial authorization:

CML diagnosis: Diagnosis of chronic myelogenous/myeloid leukemia (CML)

CML qualifying scenarios: One of the following must be true: (1) Disease is in the chronic phase AND patient has resistance or intolerance to two or more tyrosine kinase inhibitor (TKI) therapies (e.g., imatinib, dasatinib, nilotinib); OR (2) Patient has no identifiable BCR::ABL1 mutations; OR (3) Confirmed documentation of T315I mutation; OR (4) Disease is in the accelerated or blast phase AND no other kinase inhibitors are indicated.

Authorization issued for 12 months

CML Reauthorization

Reauthorization for CML:

CML reauthorization: Patient does not show evidence of progressive disease while on Iclusig therapy

Authorization issued for 12 months

Ph+ ALL Initial Authorization

Covered when ALL of the following are met for Ph+ ALL:

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

Authorization issued for 12 months

Ph+ ALL Reauthorization

Reauthorization for Ph+ ALL:

Ph+ ALL reauthorization: Patient does not show evidence of progressive disease while on Iclusig therapy

Authorization issued for 12 months

Neoplasms with eosinophilia Initial Authorization

Covered when ALL of the following are met for neoplasms with eosinophilia:

Neoplasm diagnosis: Diagnosis of lymphoid, myeloid, or mixed lineage neoplasms with eosinophilia

Genetic rearrangement: Patient has either an FGFR1 rearrangement OR an ABL1 rearrangement

Reauthorization requires no evidence of progressive disease

GIST Initial Authorization

Covered when ALL of the following are met for GIST:

GIST diagnosis: Diagnosis of gastrointestinal stromal tumor (GIST)

GIST disease state: Disease is one of: gross residual disease (R2 resection), unresectable primary disease, tumor rupture, OR recurrent/metastatic disease after progression on approved therapies (e.g., imatinib, sunitinib, regorafenib, standard dose ripretinib)

Reauthorization requires no evidence of progressive disease

Coverage criteria are subject to plan and regulatory variations. Some state mandates may supersede these criteria, including requirements for off‑label medication use or compendium references; where state mandates apply, they take precedence over the criteria in this document. In addition, coverage may be affected by member‑specific benefit plan provisions and other programs (for example, pharmacy benefit rules or external assistance programs), which may alter applicability or requirements for approval.

Step Therapy / Sequencing Requirements

Requirement	Details	Coverage status
{"text":"Disease phase requirement","status":""},{"text":"Disease is in the chronic phase of chronic myelogenous/myeloid leukemia (CML)","status":""},{"text":"Coverage requires this criterion","status":"neutral"}
{"text":"Step therapy failure requirement","status":""},{"text":"Patient has resistance or intolerance to two or more tyrosine kinase inhibitors (TKIs) (e.g., imatinib, dasatinib, nilotinib)","status":""},{"text":"Covered when met","status":"covered"}
{"text":"Exception - mutation or absent mutation","status":""},{"text":"Coverage may be granted without prior TKI failures if there is no identifiable BCR::ABL1 mutation or there is confirmed documentation of the T315I mutation","status":""},{"text":"Covered when met","status":"covered"}