Pharmacy Prior Authorization Criteria

Venclexta (venetoclax)

For diagnosis of Chronic lymphocytic leukemia or Small lymphocytic lymphoma
Indicated for the treatment of adult patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL).
For diagnosis of Acute Myeloid Leukemia
Indicated in combination with azacitidine or decitabine or low-dose cytarabine for the treatment of newly-diagnosed acute myeloid leukemia (AML) in adults who are age 75 years or older, or who have comorbidities that preclude use of intensive induction chemotherapy.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Chronic lymphocytic leukemia (CLL)/ Small Lymphocytic Lymphoma (SLL)

Diagnosis of chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL)

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Acute Myeloid Leukemia (AML)

AND

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of All indications listed above

2024-02-14, 2023-07-03, 2023-03-01, 2022-09-07, 2022-01-07, 2021-09-27, 2021-05-26, 2021-05-25, 2020-12-29, 2019-12-12, 2019-07-19

Venclexta Prescribing Information. AbbVie, Inc. North Chicago, IL. June 2022.
National comprehensive cancer network (NCCN) clinical practice guidelines in oncology. Chronic lymphocytic leukemia/small lymphocytic lymphoma. v.5.2019. Available from: https://www.nccn.org/professionals/physician_gls/pdf/cll.pdf. Accessed June 4, 2019.
The NCCN Drugs and Biologics Compendium (NCCN Compendium). Available at http://www.nccn.org/professionals/drug_compendium/content/contents.asp. Accessed on September 7, 2022.

2024-02-14: 2024 Annual Review - no criteria changes
2023-07-03: Removed specialist requirement
2023-03-01: Program update to remove NCCN supported off-label regimens within the indication-specific criteria.
2022-09-07: Updated criteria to include NCCN supported regimens.
2022-01-07: 2022 Annual Review.
2021-09-27: Addition of EHB formulary to guideline, no changes to criteria
2021-05-26: Addition of EHB formulary to guideline, no changes to criteria
2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
2020-12-29: 2021 Annual Review: updated reauthorization criteria, updated indication section (no criteria changes needed); updated references
2019-12-12: 2020 Annual Review; updated references only
2019-07-19: July P&T changes for new FDA expanded CLL/SLL labeling to remove prior therapy requirement.