Pharmacy Prior Authorization Criteria

Bosulif (bosutinib)

Indications for Prior Authorization

Bosulif (bosutinib)

• For diagnosis of Accelerated or Blast Phase Chronic Myelogenous/Myeloid Leukemia
  Indicated for the treatment of adult patients with accelerated or blast phase Philadelphia chromosome-positive (Ph+) chronic myelogenous leukemia (CML) with resistance or intolerance to prior therapy.

• For diagnosis of Chronic Phase Chronic Myelogenous Leukemia
  Indicated for the treatment of adult and pediatric patients 1 year of age and older with chronic phase (CP) Philadelphia chromosome-positive chronic myelogenous leukemia (Ph+ CML), newly-diagnosed or resistant or intolerant to prior therapy.

Criteria

Bosulif

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of Philadelphia chromosome-positive chronic myelogenous/myeloid leukemia (Ph+ CML) [1, 2]
AND
• One of the following:
• Disease is in the accelerated or blast phase
OR
• Both of the following:
• Both of the following:
• Disease is in the chronic phase
• Patient is 1 year of age or older
AND
• One of the following:
• Trial and failure, contraindication, or intolerance to BOTH of the following:
• generic dasatinib
• generic imatinib
OR
• Continuation of prior therapy

Bosulif

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient does not show evidence of progressive disease while on therapy
AND
• One of the following:
• Trial and failure, contraindication, or intolerance to BOTH of the following:
• generic dasatinib
• generic imatinib
OR
• Continuation of prior therapy

P & T Revisions

2024-11-07, 2024-06-05, 2024-01-31, 2023-11-29, 2023-07-05, 2023-03-20, 2022-03-28, 2021-09-27, 2021-05-20, 2021-05-03, 2019-11-04

References

1. Bosulif Prescribing Information. Pfizer. New York, NY. September 2023.
2. The NCCN Drugs and Biologics Compendium (NCCN Compendium). Available at http://www.nccn.org/professionals/drug_compendium/content/contents.asp. Accessed on March 18, 2020.

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Revision History

• 2024-11-07: Updated trial and failure requirement
• 2024-06-05: Annual Review - No criteria changes
• 2024-01-31: Addition of new 50 and 100mg capsules
• 2023-11-29: Guideline update due to expanded indication
• 2023-07-05: Removed specialist requirement
• 2023-03-20: Annual Review - no criteria changes
• 2022-03-28: Annual review - no changes to criteria
• 2021-09-27: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-03: Updated GPIs
• 2019-11-04: Added embedded step through generic imatinib for Brand Bosulif and allow current users to bypass the step per form strategy update

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