Nilotinib(Tasigna®) Prior Authorization Criteria

Tasigna Prior Authorization Request Form

Covered Uses

• Philadelphia chromosome positive chronic myelogenous leukemia, CML (ICD-9: 205.1) in:
  
  • Chronic phase
    
  • Accelerated phase

Exclusion Criteria

None

Required Medical Information

• Documented:
  
  • resistance to imatinib OR
    
  • disease progression to accelerated phase on imatinib OR
    
  • intolerance to imatinib

Age Restrictions

None

Prescriber Restrictions

Hematologist/oncologist

Coverage Duration

Three (3) months

Other Criteria

• Criteria for cytogenetic and hematologic response - see www.NCCN.org under CML
  
• WHO definition of CML accelerated phase - see www.NCCN.org under CML