COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Service Authorization (SA) Form

DAURISMO™ (glasdegib)

Virginia Medicaid Pharmacy Services Portal: http://www.virginiamedicaidpharmacyservices.com

© 2016 – 2019, Magellan Health, Inc. All rights reserved. Revision Date: 04/05/2019

Page 1 of 3

If the following information is not complete, correct, or legible, the SA process can be delayed.

Please use one form per member.

MEMBER INFORMATION

Last Name: First Name:

Medicaid ID Number: Date of Birth:

– –

Gender: Male Female Weight in Kilograms: ___________________________

PRESCRIBER INFORMATION

Last Name: First Name:

NPI Number:

Phone Number: Fax Number:

– – – –

DRUG INFORMATION

Drug Name/Form: ________________________________________________________________________

Strength: _________________________________________________________________________________________________________

Dosing Frequency: _________________________________________________________________________________________________________

Length of Therapy: _________________________________________________________________________________________________________

Quantity per Day: _________________________________________________________________________________________________________

(Form continued on next page.)

Virginia DMAS SA Form: DAURISMO™

Virginia Medicaid Pharmacy Services Portal: http://www.virginiamedicaidpharmacyservices.com

© 2016 – 2019, Magellan Health, Inc. All rights reserved. Revision Date: 04/05/2019

Page 2 of 3

Member’s Last Name: Member’s First Name:

DIAGNOSIS AND MEDICAL INFORMATION

For initial approval, complete the following questions to receive a 6-month approval:

1. Is the prescriber an oncologist? AND

Yes No

2. Does the member have a newly-diagnosed acute myeloid leukemia (AML)? AND

Yes No

3. Does the member have a negative pregnancy test for women of child-bearing potential? AND

Yes No

4. Does the member have a baseline QTc interval of ≤ 470 ms and does NOT have a history of long QTsyndrome? AND

Yes No

5. The member does not have severe renal impairment (e.g., eGFR < 30 mL/min) or moderate-severehepatic impairment (total bilirubin > 3 x ULN and any AST). AND

Yes No

6. The member does not have a diagnosis of AML M3 Promyelocytic Leukemia (APL) or a t(9:22)cytogenetic translocation. AND

Yes No

7. The member does not have known active, uncontrolled central nervous system (CNS) leukemia. AND

Yes No

8. Will Glasdegib be used in conjunction with subcutaneous cytarabine? AND

(Form continued on next page.)

9. Is one of the following true (either a or b)?

Yes No

a. The member is 75 years of age or older; OR

b. The member 55 years of age or older AND has one of the following:

• Severe cardiac disease (LVEF < 45% or a cumulative anthracycline dose equivalent to ≥400-550mg/m2 of doxorubicin or ≥ 125 mg/m2 of idarubicin); OR

• A serum creatinine > 1.3 mg/dL; OR

• A baseline Eastern Cooperative Oncology Group (ECOG) performance status of 2

Virginia DMAS SA Form: DAURISMO™

Virginia Medicaid Pharmacy Services Portal: http://www.virginiamedicaidpharmacyservices.com

© 2016 – 2019, Magellan Health, Inc. All rights reserved. Revision Date: 04/05/2019

Page 3 of 3

Member’s Last Name: Member’s First Name:

For renewal, complete the following questions to receive a 6-month approval:

10. Does the member continue to meet the above criteria? AND

Yes No

11. Does the member demonstrate disease stabilization or improvement as evidenced by a completeresponse (CR) (e.g., morphologic, cytogenetic or molecular complete response CR), completehematologic response or a partial response by CBC, bone marrow cytogenetic analysis, QPCR, or FISH?AND

Yes No

12. Does the member have absence of unacceptable toxicity from the drug? Examples of unacceptabletoxicity include the following: QTc-interval prolongation (e.g., interval ≥ 500 ms and/or intervalprolongation with signs and symptoms of severe arrhythmia), etc.

Yes No

Prescriber Signature (Required)

By signature, the Physician confirms the above information is accurate and verifiable by patient records.

Date

Please include ALL requested information; Incomplete forms will delay the SA process. Submission of documentation does NOT guarantee coverage by the Department of Medical Assistance Services.

The completed form may be: FAXED TO 800-932-6651, phoned to 800-932-6648, or mailed to: Magellan Medicaid Administration / ATTN: MAP 11013 W. Broad Street, Glen Allen, VA 23060