Scemblix (asciminib)
Indications for Prior Authorization
Scemblix
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For diagnosis of Philadelphia chromosome-positive chronic myeloid leukemia
Indicated for the treatment of adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (Ph+CML) in chronic phase (CP), previously treated with two or more tyrosine kinase inhibitors (TKIs). Scemblix is also indicated for the treatment of Ph+CML in CP with the T315I mutation.
Criteria
Scemblix
Prior Authorization (Initial Authorization)
Length of Approval: 12 Month(s)
- Diagnosis of chronic myelogenous/myeloid leukemia (CML) [1, 2] AND
- Disease is Philadelphia chromosome-positive (Ph+) AND
- Disease is in chronic phase AND
- One of the following:
- Both of the following:
- Patient has been previously treated with two or more alternative tyrosine kinase inhibitors (TKI) [e.g., Bosulif (bosutinib), imatinib, Sprycel (dasatinib), Tasigna (nilotinib), Iclusig (ponatinib)] AND
- Prescribed medication will be dosed at a maximum of 80 mg per day
- Both of the following:
- Disease is T315I mutation positive AND
- Prescribed medication will be dosed at a maximum of 400 mg per day
Scemblix
Prior Authorization (Reauthorization)
Length of Approval: 12 Month(s)
- Patient does not show evidence of progressive disease while on therapy
P & T Revisions
2024-07-31, 2024-01-16, 2023-06-05, 2023-01-04, 2022-08-04, 2021-12-06
References
- Scemblix [prescribing information]. East Hanover, New Jersey: Novartis Pharmaceuticals Corporation. November 2023.
- Scemblix. IBM Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Accessed December 3, 2021. http://www.micromedexsolutions.com.
Revision History
- 2024-07-31: Added new GPI
- 2024-01-16: 2024 Annual Review - updated references
- 2023-06-05: Removed prescriber requirement.
- 2023-01-04: Annual Review. No changes to criteria. Updated references
- 2022-08-04: Update to add dosing criteria to guideline
- 2021-12-06: New program for Scemblix
HEALTHY LIVING