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SPECIALTY GUIDELINE MANAGEMENT - …

Reference number(s) 1929-A Leukine SGM 2017 CVS Caremark. All rights reserved. This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written permission from CVS Caremark. This document contains prescription brand name drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. 1 SPECIALTY GUIDELINE MANAGEMENT LEUKINE (sargramostim) POLICY I. INDICATIONS The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy. A. FDA-Approved Indications 1. Use Following Induction Chemotherapy in Acute Myelogenous Leukemia a.

Reference number(s) 1929-A Leukine SGM P2017.docx © 2017 CVS Caremark. All rights reserved. This document contains confidential and proprietary information of CVS ...

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