Avastin for cervical cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with one of the following:
    • paclitaxel and cisplatin; or
    • paclitaxel and topotecan.

Avastin for glioblastoma and ovarian cancer 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Avastin for hepatocellular carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with Tecentriq (atezolizumab).

Avastin for metastatic colorectal cancer 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a regimen containing 5-fluorouracil; or
  • all of the following:
    • requested agent will be used in combination with either fluoropyrimidine-irinotecan-containing or fluoropyrimidine-oxaliplatin-containing chemotherapy; and
    • member progressed on a treatment containing bevacizumab.

Avastin for metastatic renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • if predominant clear cell histology, requested agent will be used in combination with interferon alfa.

Avastin for non-squamous non-small cell lung cancer (NSCLC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with carboplatin and paclitaxel.

Cyramza for gastric or gastro-esophageal junction (GEJ) adenocarcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a fluoropyrimidine- or platinum-containing chemotherapy regimen.

Cyramza for HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has alpha fetoprotein (AFP) ≥ 400 ng/mL; and
  • inadequate response, adverse reaction, or contraindication to Nexavar (sorafenib).

Cyramza for metastatic colorectal cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with FOLFIRI or irinotecan; and
  • previous trial with or a contraindication to a 5-fluorouracil/leucovorin or capecitabine-based regimen.

Cyramza for NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with docetaxel; and
  • inadequate response, adverse reaction, or contraindication to a platinum-containing chemotherapy regimen.

Zaltrap

• Documentation of the following is required:
  • diagnosis of metastatic colorectal cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with either irinotecan or FOLFIRI; and
  • a previous trial with one of the following regimens or a contraindication to all of the following regimens: a fluoropyrimidine (capecitabine or fluorouracil), CAPEOX, FOLFOX, oxaliplatin-based therapy; and
  • clinical rationale for use of requested agent instead of Avastin (bevacizumab).

abiraterone 250 mg, 500 mg

• Documentation of the following is required:
  • diagnosis of metastatic prostate cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • if member has metastatic high-risk castration-sensitive prostate cancer, then medication will be used in combination with prednisone and one of the following:
    • medication will be used in combination with a gonadotropin-releasing hormone (GnRH) analog; or
    • member had a bilateral orchiectomy.

Erleada for metastatic castration-sensitive prostate cancer (mCSPC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • clinical rationale for use of requested agent instead of abiraterone; and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Erleada for non-metastatic castration-resistant prostate cancer (NM-CRPC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing; and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Nubeqa

• Documentation of the following is required:
  • diagnosis of NM-CRPC; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing; and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Xtandi for mCSPC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • clinical rationale for use of requested agent instead of abiraterone; and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Xtandi for metastatic prostate cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Xtandi for NM-CRPC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing; and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Yonsa

• Documentation of the following is required:
  • diagnosis of metastatic prostate cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with methylprednisolone; and
  • one of the following:
    • medication will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Jelmyto

• Documentation of the following is required:
  • diagnosis of low-grade upper tract urothelial cancer; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing.

Besponsa

• Documentation of the following is required:
  • diagnosis of ALL; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • Philadelphia chromosome-positive; and
      • inadequate response or adverse reaction to one tyrosine kinase inhibitor for the treatment of ALL; or
    • all of the following:
      • Philadelphia chromosome-negative; and
      • B-cell precursor ALL; and
      • prior therapy for the treatment of ALL with one systemic therapy.

Mylotarg for newly-diagnosed CD33-positive AML in adults

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • requested agent will be used in combination with daunorubicin and cytarabine; or
    • clinical rationale why combination therapy with daunorubicin and cytarabine is not appropriate.

Mylotarg for relapsed or refractory CD33-positive AML 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ two years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • relapsed or refractory AML; or
    • prior therapy for the treatment of AML with one systemic therapy.

Trodelvy

• Documentation of the following is required:
  • diagnosis of metastatic triple-negative breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to at least two prior therapies for metastatic disease.

Soltamox for metastatic breast cancer in women and men, node-positive breast cancer in postmenopausal women following total mastectomy or segmental mastectomy, axillary dissection, or breast irradiation, invasive breast cancer in women with ductal carcinoma in situ (DCIS), and women at high risk for breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • medical necessity for oral tamoxifen solution formulation (i.e., dysphagia).

Arranon

• Documentation of the following is required:
  • diagnosis of T-cell acute lymphoblastic leukemia (T-ALL) or T-cell lymphoblastic lymphoma (T-LBL); and
  • prescriber is an oncologist; and
  • appropriate dosing.

Infugem

• Documentation of the following is required:
  • diagnosis of breast cancer, non-small cell lung cancer, ovarian cancer or pancreatic cancer; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • clinical rationale for use over gemcitabine product available without prior authorization.

Purixan

• Documentation of the following is required:
  • diagnosis of acute lymphoblastic leukemia (ALL); and
  • one of the following:
    • member is < 13 years of age; or
    • medical necessity for the use of an oral suspension formulation (e.g. swallowing disorder).

SmartPA: Claims for Purixan (mercaptopurine oral suspension) will usually process at the pharmacy without a PA request if the member has a MassHealth history of medical claims for ALL and the member is < 13 years of age. ^†

Jevtana

• Documentation of the following is required:
  • diagnosis of metastatic prostate cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one docetaxel-containing regimen.

Asparlas

• Documentation of the following is required:
  • diagnosis of ALL; and
  • member is ≥ one month and < 22 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to Oncaspar (pegaspargase); or
  • clinical rationale for use instead of Oncaspar (pegaspargase).

Erwinaze

• Documentation of the following is required:
  • diagnosis of ALL; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • hypersensitivity to E. coli-derived asparaginase.

Elzonris

• Documentation of the following is required:
  • diagnosis of blastic plasmacytoid dendritic cell neoplasm (BPDCN); and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • first infusion will take place in an inpatient setting, and subsequent infusions may take place in an outpatient setting with appropriate monitoring.

fulvestrant

• Documentation of the following is required:
  • diagnosis of hormone receptor-positive metastatic breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is postmenopausal or has received ovarian ablation or suppression; and
  • one of the following:
    • requested agent will be used as monotherapy; or
    • requested agent will be used in combination with a CDK inhibitor (abemaciclib, palbociclib, or ribociclib); or
    • requested agent will be used in combination with anastrozole or letrozole.

Daurismo

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with low dose cytarabine; and
  • request is within quantity limit of one unit/day; and
  • one of the following:
    • member is ≥ 75 years of age; or
    • member is ≥ 60 years of age and one of the following:
      • member is not a candidate for intensive induction chemotherapy; or
      • member has significant comorbidities that preclude the use of intensive induction chemotherapy.

Erivedge and Odomzo

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dose; and
  • member is ≥ 18 years of age; and
  • member has persistent or recurring basal cell carcinoma following surgery and/or radiation therapy; or
  • member is not a candidate for surgery and/or radiation therapy.

Beleodaq and romidepsin for peripheral T-cell lymphoma (PTCL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to one second-line treatment option; or
    • contraindication to all second-line treatment options.

Farydak

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response to bortezomib; and
  • quantity limit of six capsules for a 21 day supply; and
  • concomitant therapy with bortezomib and dexamethasone; and
  • inadequate response or adverse reaction to one of the following immunomodulatory agents or contraindication to all of the following immunomodulatory agents:
    • Revlimid (lenalidomide); or
    • Thalomid (thalidomide); or
    • Pomalyst (pomalidomide).

romidepsin for cutaneous T-cell lymphoma (CTCL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist, hematologist or dermatologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to Zolinza (vorinostat); and
  • inadequate response, adverse reaction, or contraindication to one of the following agents:
    • Interferon (Actimmune or Intron A); or
    • bexarotene capsules.

Pomalyst for multiple myeloma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to Revlimid (lenalidomide); and
  • inadequate response or adverse reaction to one of the following proteasome inhibitors or contraindication to both proteasome inhibitors:
    • bortezomib; or
    • Kyprolis (carfilzomib); or
    • Ninlaro (ixazomib).

Pomalyst for Kaposi sarcoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has acquired immunodeficiency syndrome (AIDS) and has failed highly active antiretroviral therapy; or
    • member is human immunodeficiency virus (HIV)-negative; and
  • inadequate response, adverse reaction, or contraindication to pegylated liposomal doxorubicin and paclitaxel.

Revlimid

• Documentation of the following is required:
  • diagnosis of follicular lymphoma (FL), marginal zone lymphoma (MZL), multiple myeloma, myelodysplastic syndrome, or mantle cell lymphoma (MCL); and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • if the request is for the 2.5 mg, 5 mg, or 10 mg strength, quantity limit of one unit/day; or
    • if the request is for the 15 mg, 20 mg, or 25 mg strength, quantity limit of 21 capsules for a 28 day supply; and
  • if the request is for treatment of FL or MZL, documentation that the requested agent will be used in combination with rituximab; or 
  • if the request is for previously untreated MZL, documentation of clinical rationale for use instead of any of the following: 
    
    • bendamustine + rituximab; or
    • rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP); or
    • rituximab, cyclophosphamide, vincristine, and prednisone (RCVP); or
    • rituximab.

SmartPA: Claims within quantity limits for Revlimid (lenalidomide) will usually process at the pharmacy without a PA request if the member has a MassHealth history of medical claims for multiple myeloma. ^†

Aliqopa

• Documentation of the following is required:
  • diagnosis of follicular lymphoma (FL); and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of FL with at least two systemic therapies.

Balversa

• Documentation of the following is required:
  • diagnosis of FGFR3- or FGFR2-mutated locally advanced or metastatic urothelial carcinoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has received prior treatment with platinum-containing chemotherapy or is not a candidate for platinum-containing chemotherapy.

Braftovi for unresectable or metastatic melanoma

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E or V600K mutation; and
  • requested agent will be used in combination with Mektovi (binimetinib).

Braftovi for metastatic colorectal cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E mutation; and
  • requested agent will be used in combination with Erbitux (cetuximab) or Vectibix (panitumumab); and
  • inadequate response or adverse reaction to one or a contraindication to all of the following regimens: CAPEOX, FOLFOX, irinotecan-based therapy, oxaliplatin-based therapy.

Copiktra for chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of CLL/SLL with at least two prior therapies.

Copiktra for FL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of FL with at least two systemic therapies.

Cotellic

• Documentation of the following is required:  
  • diagnosis of unresectable or metastatic melanoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E or V600K mutation; and
  • requested agent will be used in combination with Zelboraf (vemurafenib).

Gilotrif

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has epidermal growth factor receptor (EGFR) mutations; or
    • inadequate response or adverse reaction to at least one platinum-based chemotherapy regimen; or
    • contraindication to the use of platinum-based chemotherapy; and
  • request is within quantity limit of one unit/day.

Ibrance for HER2-negative, ER-positive breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • if applicable, member is postmenopausal or has received ovarian ablation or suppression; and
  • one of the following:
    • the requested agent will be used in combination with an aromatase inhibitor; or
    • the requested agent will be used in combination with fulvestrant; and
  • request is within quantity limit of one unit/day.

Jakafi for acute graft versus host disease (aGVHD)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 12 years of age; and
  • inadequate response, adverse reaction, or contraindication to systemic glucocorticoids; and
  • request is within quantity limit of two units/day.

Jakafi for polycythemia vera (PV)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to hydroxyurea; and
  • request is within quantity limit of two units/day.

Jakafi for intermediate or high-risk PMF, post-PV MF, or post-ET MF

• Documentation of the following is required:
  • appropriate diagnosis; and
  • request is within quantity limit of two units/day.

Kisqali

• Documentation of the following is required:
  • diagnosis of HER2-negative ER-positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • the requested agent will be used in combination with an aromatase inhibitor; or
    • the requested agent will be used in combination with fulvestrant.

Kisqali-Femara Co-Pack

• Documentation of the following is required:
  • diagnosis of HER2-negative ER-positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is postmenopausal or has received ovarian ablation or suppression.

Koselugo

• Documentation of the following is required:
  • diagnosis of plexiform neurofibromas with neurofibromatosis type 1; and
  • prescriber is a neurologist or oncologist; and
  • appropriate dosing; and
  • member is ≥ two years of age and < 18 years of age at the start of therapy; and
  • member has at least one measurable plexiform neurofibroma with documentation that complete resection of plexiform neurofibroma is not feasible without substanstial risk or morbidity.

Lenvima for advanced renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested regimen includes everolimus; and
  • one of the following:
    • tumor is clear cell histology and inadequate response or adverse reaction to one or contraindication to all first-line therapies; or
    • tumor is non-clear cell histology and inadequate response or adverse reaction to one or contraindication to all systemic therapies.

Lenvima for differentiated thyroid cancer (DTC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Lenvima for endometrial carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one prior line of systemic therapy or contraindication to systemic therapy; and 
  • requested agent will be used in combination with Keytruda (pembrolizumab).

Lenvima for unresectable hepatocellular carcinoma (HCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Lorbrena

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is ALK-positive; and
  • one of the following:
    • inadequate response or adverse reaction to Xalkori (crizotinib) and at least one other ALK inhibitor; or
    • inadequate response or adverse reaction to Alecensa (alectinib) or Zykadia (ceritinib); and
  • request is within quantity limit of one unit/day.

Mekinist for locally advanced or metastatic anaplastic thyroid cancer

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E mutation; and
  • requested agent will be used in combination with Tafinlar (dabrafenib); and
  • member has no satisfactory locoregional treatment options.

Mekinist for adjuvant treatment of melanoma 

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E or V600K mutation; and
  • requested agent will be used in combination with Tafinlar (dabrafenib); and
  • member has lymph node involvement and complete resection.

Mekinist for unresectable or metastatic melanoma 

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E or V600K mutation; and
  • one of the following:
    • requested agent will be used in combination with Tafinlar (dabrafenib); or
    • all of the following:
      • requested agent will be used as a single agent; and
      • no history of prior therapy with a BRAF inhibitor (i.e., Tafinlar [dabrafenib] or Zelboraf [vemurafenib]); and
      • clinical rationale for bypassing use of a BRAF inhibitor (i.e., Tafinlar [dabrafenib] or Zelboraf [vemurafenib]).

Mekinist for NSCLC

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E mutation; and
  • requested agent will be used in combination with Tafinlar (dabrafenib).

Mektovi

• Documentation of the following is required:  
  • diagnosis of unresectable or metastatic melanoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E or V600K mutation; and
  • requested agent will be used in combination with Braftovi (encorafenib).

Nerlynx for extended adjuvant treatment of early stage HER2-postive breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member received trastuzumab therapy within the past two years; and
  • request is within quantity limit of six units/day.

Nerlynx for treatment of metastatic HER2-postive breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to two anti-HER2-based regimens; and
  • requested agent will be used in combination with capecitabine; and
  • request is within quantity limit of six units/day.

Pemazyre

• Documentation of the following is required:
  • unresectable locally advanced or metastatic cholangiocarcinoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor has FGFR2 fusion or other rearrangement; and
  • member is ≥ 18 years of age; and
  • member has received at least one prior treatment; and
  • request is within quantity limit of 14 tablets for a 21 day supply.

Piqray 

• Documentation of the following is required:
  • diagnosis of HER2-negative, HR-positive, PIK3CA-mutated breast cancer in men and postmenopausal women; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • disease has progressed following treatment with endocrine-based therapy; and
  • requested agent will be used in combination with fulvestrant.

Qinlock

• Documentation of the following is required:
  • diagnosis of gastrointestinal stromal tumor; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to at least three prior kinase inhibitor therapies, one of which is imatinib; and
  • request is within quantity limit of three units per day.

Retevmo for advanced or metastatic RET-mutant medullary thyroid cancer or RET-fusion positive thyroid cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 12 years of age; and
  • request is within quantity limit of four capsules/day; and
  • one of the following:
    • member has thyroid cancer and one of the following: member refractory to radioactive iodine or radioactive iodine treatment is not appropriate; or
    • member has medullary thyroid cancer.

Retevmo for metastatic RET fusion-positive non-small cell lung cancer 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • request is within quantity limit of four capsules/day.

Rozlytrek for solid tumors with neurotrophic receptor tyrosine kinase (NTRK) gene fusion without a known acquired resistance mutation

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • tumor is metastatic; or
    • member is not a candidate for surgical resection; and
  • one of the following:
    • requested agent is first-line for the requested indication; or
    • member has no satisfactory alternative treatment options; or
    • disease has progressed following at least one first-line treatment for the requested indication (e.g., chemotherapy, radiation, surgical intervention).

Rozlytrek for ROS1-positive metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is ROS1 positive.

Stivarga for gastrointestinal stromal tumor (GIST)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to both of the following: imatinib and Sutent (sunitinib).

Stivarga for HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has Child-Pugh Class A; and
  • inadequate response, adverse reaction, or contraindication to Nexavar (sorafenib).

Stivarga for metastatic colorectal cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one of the following regimens, or a contraindication to all of the following regimens: CAPEOX, FOLFIRI, FOLFOX, FOLFOXIRI, irinotecan-based therapy, oxaliplatin-based therapy; and
  • if BRAF/KRAS/NRAS wild-type cancer is present, inadequate response or adverse reaction to one of the following, or a contraindication to both of the following: Erbitux (cetuximab), Vectibix (panitumumab).

Tabrecta

• Documentation of the following is required:
  • diagnosis of advanced or metastatic non-small cell lung cancer; and
  • Prescriber is an oncologist; and
  • Appropriate dosing; and
  • Cancer has mutation that leads to MET exon 14 skipping; and
  • request is within quantity limit of four tablets/day

Tafinlar for locally advanced or metastatic anaplastic thyroid cancer

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E mutation; and
  • requested agent will be used in combination with Mekinist (trametinib); and
  • member has no satisfactory locoregional treatment options.

Tafinlar for adjuvant treatment of melanoma 

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E or V600K mutation; and
  • requested agent will be used in combination with Mekinist (trametinib); and
  • member has lymph node involvement and complete resection.

Tafinlar for unresectable or metastatic melanoma

•  Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E or V600K mutation.

Tafinlar for NSCLC

•  Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E mutation; and
  • requested agent will be used in combination with Mekinist (trametinib).

Tagrisso

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • request is within quantity limit of one unit/day; and
  • one of the following:
    • cancer displays the EGFR exon 19 deletion or exon 21 L858R mutation; or
    • cancer displays the EGFR mutation and the T790M resistance mutation; or
    • inadequate response or adverse reaction to one or contraindication to all of the following: erlotinib, Gilotrif (afatinib), Iressa (gefitinib), Vizimpro (dacomitinib).

Verzenio

• Documentation of the following is required:
  • diagnosis of HR-positive, HER2-negative advanced or metastatic breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is postmenopausal or has received ovarian ablation or suppression; and
  • one of the following:
    • the requested agent will be used in combination with an aromatase inhibitor; or
    • the requested agent will be used in combination with fulvestrant; or
    • the requested agent will be used as monotherapy when disease has progressed after both hormonal therapy and chemotherapy; and
  • request is within quantity limit of two tablets/day.

Vitrakvi

• Documentation of the following is required:
  • diagnosis of solid tumors with NTRK gene fusion without a known acquired resistance mutation; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • tumor is metastatic; or
    • member is not a candidate for surgical resection; and
  • one of the following:
    • requested agent is first-line for the requested indication; or
    • member has no satisfactory alternative treatment options; or
    • disease has progressed following at least one first-line treatment for the requested indication (e.g., chemotherapy, radiation, surgical intervention); and
  • if the request is for oral solution formulation, medical necessity for the use of an oral solution formulation (e.g., swallowing disorder) must be provided.

Vizimpro

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has epidermal growth factor receptor (EGFR) mutations; and
  • request is within quantity limit of one unit/day.

Zydelig for CLL

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • relapsed or refractory CLL; or
    • prior therapy for the treatment of CLL with at least one systemic therapy; and
  • inadequate response, adverse reaction, or contraindication to Imbruvica (ibrutinib).

Zydelig for FL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of FL with at least two systemic therapies.

Zydelig for SLL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of SLL with at least two systemic therapies.

Fusilev, Khapzory, and levoleucovorin injection

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ six years of age; and
  • medical records documenting member is not a candidate for leucovorin therapy due to hypersensitivity to a component of leucovorin; and
  • if the request is for Khapzory, rationale for use over Fusilev (levoleucovorin powder for injection).

Idhifa

• Documentation of the following is required:  
  • diagnosis of IDH2-mutated AML; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • request is within quantity limit of one unit/day; and
  • member is ≥ 60 years of age and is not a candidate for intensive remission induction therapy; or
  • relapsed or refractory IDH2-mutated AML; or
  • prior treatment of IDH2-mutated AML with at least one systemic therapy.

Imlygic

• Documentation of the following is required:
  • diagnosis of melanoma; and 
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • unresectable cutaneous, subcutaneous, or nodal lesions; and
  • melanoma is recurrent after initial surgery.

Lonsurf

• For metastatic colorectal cancer, documentation of the following is required:
  • diagnosis of metastatic colorectal cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to at least one of the following regimens, or contraindication to all of the following regimens: CAPEOX, FOLFOX, FOLFIRI, FOLFOXIRI, irinotecan-based therapy, oxaliplatin-based therapy; and
  • if BRAF/KRAS/NRAS wild-type cancer is present, inadequate response or adverse reaction to one of the following, or contraindication to both of the following: Erbitux (cetuximab), Vectibix (panitumumab).
• For metastatic gastric or GEJ adenocarcinoma, documentation of the following is required:
  • diagnosis of metastatic gastric or GEJ adenocarcinoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to at least two prior lines of chemotherapy that included a fluoropyrimidine, a platinum, either a taxane or irinotecan, and if appropriate, HER2/neu-targeted therapy; or
    • contraindication to chemotherapy and HER2/neu-targeted therapy.

Lumoxiti

• Documentation of the following is required:
  • diagnosis of relapsed or refractory hairy cell leukemia (HCL); and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of HCL with at least two systemic therapies, including at least one purine nucleoside analog (PNA).

Provenge

• Documentation of the following is required:
  • diagnosis of metastatic prostate cancer; and 
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • ECOG score 0-1 (good performance status); and
  • estimated life expectancy > six months; and
  • no hepatic metastases; and
  • no/minimal symptoms; and
  • requested quantity does not exceed three doses (one complete cycle).

Synribo

• Documentation of the following is required:
  • diagnosis of chronic myelogenous leukemia (CML); and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to two or contraindication to all of the following: Bosulif (bosutinib), imatinib, Sprycel (dasatinib), Tasigna (nilotinib); or
    • confirmed T315I mutation.

Tazverik

• Documentation of the following is required:  
  • diagnosis of metastatic or locally advanced epithelioid sarcoma not eligible for complete resection; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • request is within quantity limit of eight units/day; and
  • member is ≥ 16 years of age. 

Tibsovo

• Documentation of the following is required:  
  • diagnosis of IDH1-mutated AML; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • request is within quantity limit of two units/day; and
  • member is ≥ 60 years of age and is not a candidate for chemotherapy; or
  • relapsed or refractory IDH1-mutated AML; or
  • prior treatment of IDH1-mutated AML with at least one systemic therapy.

Venclexta for AML

• Documentation of the following is required:  
  • diagnosis of AML; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member is ≥ 60 years of age; or
    • clinical rationale for use of requested agent instead of intensive induction chemotherapy; and
  • requested agent will be used in combination with azacitidine, decitabine, or low-dose cytarabine.

Venclexta for CLL or SLL

• Documentation of the following is required:  
  • diagnosis of CLL or SLL; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has not received treatment for CLL or SLL and both of the following:
      • requested agent will be used in combination with Gazyva (obinutuzumab); and
      • clinical rationale for use of the requested agent instead of Imbruvica (ibrutinib); or
    • prior therapy for the treatment of CLL or SLL with at least one systemic therapy and requested agent will be used in combination with Rituxan (rituximab).

Vyxeos

• Documentation of the following is required:  
  • diagnosis of newly diagnosed therapy-related AML or AML with myelodysplasia-related changes (AML-MRC); and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • clinical rationale for use over separate daunorubicin and cytarabine chemotherapy agents.

Xofigo

• Documentation of the following is required:
  • diagnosis of metastatic prostate cancer with metastasis to the bone; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member does not have visceral metastatic disease.

Xpovio

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has received at least four prior chemotherapy regimens or contraindication to the use of recommended chemotherapy regimens; and
  • member’s disease is refractory to at least two proteasome inhibitors or that the member has a contraindication to all proteasome inhibitors; and
  • member’s disease is refractory to at least two immunomodulatory agents or that the member has a contraindication to all immunomodulatory agents; and
  • member’s disease is refractory to Darzalex (daratumumab) or that the member has a contraindication to use of Darzalex (daratumumab); and
  • requested medication will be used in combination with dexamethasone

Zelboraf for Erdheim-Chester Disease

• Documentation of the following is required:
  • appropriate diagnosis; and 
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600 mutation.

Zelboraf for unresectable or metastatic melanoma

• Documentation of the following is required:
  • appropriate diagnosis; and 
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF-V600E mutation.

Adcetris for relapsed or refractory Hodgkin Lymphoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member is at high risk of relapse as post autologous hematopoietic stem cell transplantation (auto-HSCT); or
    • inadequate response to auto-HSCT; or
    • member is not a candidate for auto-HSCT and inadequate response or adverse reaction to two prior multi-agent chemotherapy regimens; or
    • clinical rationale as to why the other available treatment regimens cannot be used.

Adcetris for treatment-naïve Hodgkin Lymphoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with doxorubicin, vinblastine, and dacarbazine.

Adcetris for primary cutaneous anaplastic large cell lymphoma (pcALCL) or CD30-expressing mycosis fungoides (MF)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to one systemic therapy; or
    • contraindication to the use of systemic therapy.

Adcetris for previously untreated CD-30 expressing PTCL, including systemic anaplastic large cell lymphoma (sALCL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested agent will be used with cyclophosphamide, doxorubicin, and prednisone.

Adcetris for sALCL after failure of at least one prior multiagent chemotherapy regimen

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to one prior chemotherapy regimen or agent; or
    • clinical rationale as to why the other available treatment regimens cannot be used.

Halaven for metastatic or recurrent breast cancer 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • two prior chemotherapy regimens that included an anthracycline and a taxane; and
  • inadequate response, adverse reaction or contraindication to vinorelbine (may have been part of prior chemotherapy regimens).

Halaven for unresectable or metastatic liposarcoma 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to an anthracycline-containing regimen.

Polivy

• Documentation of the following is required:
  • diagnosis of diffuse large B-cell lymphoma (DLBCL); and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to two systemic therapies; or
    • contraindication to the use of systemic therapy.

Arzerra for relapsed or refractory CLL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to fludarabine; and
  • inadequate response, adverse reaction, or contraindication to alemtuzumab.

Arzerra for untreated CLL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • contraindication to fludarabine; and
  • one of the following:
    • requested agent will be used in combination with chlorambucil; or
    • clinical rationale as to why the agent will not be used with chlorambucil.

Blincyto

• Documentation of the following is required:
  • diagnosis of ALL; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member with complete remission and MRD positive B-ALL; or 
    • both of the following:
      • Philadelphia chromosome-positive; and
      • inadequate response or adverse reaction to one tyrosine kinase inhibitor for the treatment of ALL; or
    • all of the following:
      • Philadelphia chromosome-negative; and
      • B-cell precursor ALL; and
      • prior therapy for the treatment of ALL with one systemic therapy.

Darzalex and Darzalex Faspro

• Documentation of the following is required for monotherapy:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all of the following proteasome inhibitors: bortezomib, Kyprolis (carfilzomib), Ninlaro (ixazomib); and
  • inadequate response or adverse reaction to one or contraindication to all of the following immunomodulatory agents: Revlimid (lenalidomide), Thalomid (thalidomide), Pomalyst (pomalidomide); and
  • one of the following:
    • inadequate response or adverse reaction to one proteasome inhibitor and one immunomodulatory agent noted above; or
    • history of a total of three trials with chemotherapy regimens for the requested indication.

• Documentation of the following is required for combination therapy:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to at least one prior chemotherapy regimen for the requested indication and one of the following:
      • requested agent will be used in combination with Revlimid (lenalidomide) and dexamethasone; or
      • requested agent will be used in combination with bortezomib and dexamethasone; or
    • if the request is for Darzalex, inadequate response or adverse reaction to two prior chemotherapy regimens for the requested indication and requested medication will be used in combination with Pomalyst (pomalidomide) and dexamethasone; or
    • member is newly diagnosed and ineligible for autologous stem cell transplant (ASCT), and one of the following:
      • requested medication will be used in combination with Revlimid (lenalidomide) and dexamethasone; or
      • requested medication will be used in combination with bortezomib, melphalan, and prednisone; or
    • if the request is for Darzalex, member is newly diagnosed and eligible for autologous stem cell transplant (ASCT) and all of the following:
      • requested medication will be used in combination with thalidomide, dexamethasone and bortezomib; or
      • rationale for use of the requested regimen instead of a preferred regimen for this indication.

Empliciti

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • inadequate response or adverse reaction to at least one prior chemotherapy regimen for the requested indication; and
      • requested agent will be used in combination with Revlimid (lenalidomide) and dexamethasone; or
    • all of the following:
      • inadequate response or adverse reaction to at least two prior chemotherapy regimens for the requested indication; and
      • inadequate response or adverse reaction to one or contraindication to all of the following proteasome inhibitors: bortezomib, Kyprolis (carfilzomib), Ninlaro (ixazomib); and
      • inadequate response, adverse reaction, or contraindication to Revlimid (lenalidomide); and
      • requested medication will be used in combination with Pomalyst (pomalidomide) and dexamethasone.

Enhertu 

• Documentation of the following is required:
  • diagnosis of recurrent or metastatic HER2-positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to two anti-HER2-based regimens.

Gazyva for CLL or SLL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has CLL or SLL without del(17p)/TP53 mutation; or
    • member has CLL or SLL with del(17p)/TP53 mutation AND is treatment naive.

Gazyva for FL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • relapsed or refractory FL after treatment with a rituximab-containing regimen; or
    • concurrent therapy with first-line chemotherapy agent.

Kadcyla

• Documentation of the following is required:
  • diagnosis of HER-2 positive recurrent or metastatic breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has recurrent or metastatic breast cancer and an inadequate response or adverse reaction to trastuzumab and a taxane, separately or in combination; or
    • member has early breast cancer (EBC) and residual invasive disease after neoadjuvant taxane and trastuzumab-based treatment.

Monjuvi for diffuse large B cell lymphoma (DLBCL)

• Documentation of the following is required: 
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following: 
    • inadequate response or adverse reaction to one systemic therapy; or
    • contraindication to all systemic therapies. 

Perjeta 

• Documentation of the following is required:
  • diagnosis of HER-2 positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • for recurrent or stage IV disease, requested agent will be used in combination with Herceptin (trastuzumab) and docetaxel or paclitaxel; or
    • for adjuvant or neoadjuvant chemotherapy, requested agent will be used in combination with trastuzumab and chemotherapy.

Portrazza 

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer of squamous cell histology; and
  • requested agent will be used in combination with gemcitabine and cisplatin; and
  • medical necessity for use of the requested agent over all other clinically appropriate alternatives.

Poteligeo for mycosis fungoides

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • Stage IA to IIA disease and member is refractory to skin-directed therapy; or
    • Stage IIB disease; or
    • Stage III disease with blood involvement; or
    • diagnosis of large-cell transformed or follicular mycosis fungoides.

Poteligeo for Sézary syndrome

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing.

Rituxan, Rituxan Hycela, Ruxience, and Truxima for CLL 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • one of the following:
    • concurrent therapy with at least one other chemotherapy agent; or
    • clinical rationale as to why the agent is being used as monotherapy.

Rituxan and Ruxience for Granulomatosis with Polyangiitis (GPA) and Microscopic Polyangiitis (MPA)

• For induction (initial) therapy, documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to cyclophosphamide; and
  • one of the following:
    • concurrent use with a glucocorticoid; or
    • adverse reaction or contraindication to glucocorticoids.
• For maintenance (subsequent) therapy, documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: azathioprine, methotrexate, mycophenolate.

Rituxan, Ruxience, and Truxima for Non-Hodgkin’s Lymphoma (NHL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing.

Rituxan for Pemphigus Vulgaris (PV)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one systemic corticosteroid or contraindication to all systemic corticosteroids; and
  • inadequate response or adverse reaction to one systemic immunosuppressive therapy (azathioprine, mycophenolate, cyclophosphamide) or contraindication to all systemic immunosuppressive therapy.

Rituxan for Rheumatoid Arthritis (RA) 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • inadequate response, adverse reaction or contraindication to one TNF antagonist; and
  • one of the following:
    • concurrent therapy with methotrexate; or
    • contraindication or adverse reaction to methotrexate.

Rituxan Hycela for diffuse large B-cell lymphoma 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • one of the following:
    • concurrent therapy with at least one other chemotherapy agent; or
    • clinical rationale as to why the agent is being used as monotherapy.

Rituxan Hycela for FL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing.

Sarclisa

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all of the following proteasome inhibitors: bortezomib, Kyprolis (carfilzomib), Ninlaro (ixazomib); and
  • inadequate response, adverse reaction, or contraindication to Revlimid (lenalidomide); and
  • history of a total of at least two trials with appropriate regimens for the requested indication; and
  • requested medication will be used in combination with Pomalyst (pomalidomide) and dexamethasone.

Yervoy for hepatocellular carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with Opdivo (nivolumab); and
  • inadequate response, adverse reaction, or contraindication to Nexavar (sorafenib).

Yervoy for metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • PD-L1 expression ≥ 1% and requested agent will be used in combination with Opdivo (nivolumab); or
    • requested agent will be used in combination with Opdivo (nivolumab) and two cycles of platinum doublet chemotherapy.

Yervoy for microsatellitle instability-high (MSI-H)/mismatch repair deficient (dMMR) metastatic colorectal cancer (mCRC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with Opdivo (nivolumab); and
  • member received treatment with a fluoropyrimidine-, oxaliplatin-, or irinotecan-based therapy.

Yervoy for renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has clear cell histology; and
  • one of the following:
    • member has poor/intermediate risk disease; or
    • member has had treatment with one previous line of therapy; and
  • requested agent will be used in combination with Opdivo (nivolumab).

Yervoy for stage III (lymph node involvement) and stage IV (metastatic) melanoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member previously received Opdivo (nivolumab) or Keytruda (pembrolizumab); or
    • clinical rationale as to why the requested agent is appropriate over anti-PD-1 therapy.

Padcev

• Documentation of the following is required:
  • diagnosis of locally advanced or metastatic urothelial cancer; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or consult notes from an oncologist are provided; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to platinum-based chemotherapy; or
    • contraindication to all platinum-based chemotherapy; and
  • one of the following:
    • inadequate response or adverse reaction to a PD-1 inhibitor or PD-L1 inhibitor therapy; or
    • contraindication to all PD-1 inhibitor and PD-L1 inhibitor therapies.

Bavencio and Keytruda for metastatic Merkel cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Bavencio and Keytruda for first-line treatment of RCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor is clear cell histology; and
  • requested agent will be used in combination with Inlyta (axitinib).

Bavencio for urothelial carcinoma (UC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen; or
    • disease has not progressed following treatment with four to six cycles of first-line platinum-containing chemotherapy.

Imfinzi for Stage III NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy.

Imfinzi for extensive-stage (ES) SCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has extensive stage disease; and
  • requested agent will be used in combination with etoposide and either carboplatin or cisplatin.

Imfinzi and Opdivo for UC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen.

Keytruda for non-muscle invasive bladder cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to BCG; and
  • disease is high-risk with carcinoma in situ.  

Keytruda for cervical cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • PD-L1 expression [combined positive score (CPS) ≥ 1]; and
  • inadequate response or adverse reaction to one systemic chemotherapy regimen, or contraindication to the use of systemic chemotherapy.

Keytruda for microsatellite instability-high (MSI-H)/mismatch repair deficient (dMMR) solid tumors or metastatic colorectal cancer (mCRC) 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Keytruda for endometrial carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one prior line of systemic therapy or contraindication to systemic therapy; and
  • requested agent will be used in combination with Lenvima (lenvatinib).

Keytruda for recurrent locally advanced or metastatic gastric or GEJ adenocarcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • if microsatellite instability-high (MSI-H)/mismatch repair deficient (dMMR), at least one prior treatment regimen with systemic therapy including fluoropyrimidine- and platinum-containing chemotherapy and if appropriate, HER2/neu-targeted therapy; or
    • if PD-L1-positive, at least two prior treatment regimens with systemic therapy including fluoropyrimidine- and platinum-containing chemotherapy and if appropriate, HER2/neu-targeted therapy.

Keytruda for HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has Child-Pugh Class A; and
  • inadequate response, adverse reaction, or contraindication to Nexavar (sorafenib).

Keytruda and Opdivo for Hodgkin Lymphoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has progressed after autologous hematopoietic stem cell transplant with or without brentuximab; or
    • member is ineligible for transplant or failure of two or more lines of prior chemotherapy; or
    • member has received allogeneic transplant.

Keytruda for recurrent or metastatic head and neck squamous cell carcinoma (HNSCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen; or
  • cancer is non-nasopharyngeal and one of the following:
    • requested agent is used in combination with a platinum agent (cisplatin, carboplatin) and fluorouracil; or 
    • tumor is PD-L1 positive (CPS ≥ 1).

Keytruda and Opdivo for stage III (lymph node involvement) and stage IV (metastatic) melanoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Keytruda for stage III NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • PD-L1 expression [tumor proportion score (TPS) ≥ 1%]; and
  • requested agent will be used in combination with carboplatin and either pemetrexed or paclitaxel.

Keytruda for unresectable or metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • requested agent will be used in combination with pemetrexed and either carboplatin or cisplatin for nonsquamous NSCLC in the first-line setting; or
    • requested agent will be used in combination with carboplatin and either paclitaxel or albumin-bound paclitaxel for squamous NSCLC in the first-line setting; or
    • PD-L1 expression and an inadequate response, adverse reaction or contraindication to a platinum-containing regimen; or
    • all of the following:
      • PD-L1 expression ≥ 50% of tumor cells; and
      • member does not have EGFR or ALK genomic tumor aberrations; and
      • member has not had prior systemic chemotherapy for this indication.

Keytruda for primary mediastinal B-cell lymphoma (PMBCL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to two systemic chemotherapy regimens, or contraindication to the use of systemic chemotherapy.

Keytruda for metastatic squamous cell carcinoma of the esophagus (ESCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor expresses PD-L1 (CPS ≥ 10]; and
  • inadequate response, adverse reaction, or contraindication to at least one line of systemic therapy.

Keytruda and Opdivo for metastatic small cell lung cancer (SCLC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to one line of platinum-based chemotherapy.

Keytruda and Libtayo for metastatic or locally advanced cutaneous squamous cell carcinoma (CSCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing;  and
  • member is ≥ 18 years of age; and
  • member is not a candidate for surgery and/or radiation therapy.

Keytruda for tumor mutational burden-high (TMB-H) cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing;  and
  • tumor has ≥ 10 mutations/megabase.

Keytruda for UC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • if treatment-naïve, PD-L1 expression with CPS ≥ 10, or member is not a candidate for any platinum-containing chemotherapy due to poor performance status; and
  • one of the following:
    • inadequate response or adverse reaction to a regimen containing cisplatin; or
    • contraindication to cisplatin and inadequate response or adverse reaction to a regimen containing gemcitabine and carboplatin; or
    • contraindication to cisplatin and contraindication to gemcitabine or carboplatin.

Opdivo for advanced renal cell carcinoma 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • tumor is non-clear cell histology and the requested agent will be used as monotherapy; or
    • tumor is clear cell histology and inadequate response or adverse reaction to one or contraindication to all first-line therapies; or
    • tumor is clear cell histology and requested agent will be used in combination with ipilimumab.

Opdivo for HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has Child-Pugh Class A or B; and
  • inadequate response, adverse reaction, or contraindication to Nexavar (sorafenib).

Opdivo for recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen.

Opdivo for MSI-H/dMMR mCRC 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to a fluoropyrimidine, oxaliplatin, and irinotecan-containing regimen; or
    • contraindication to a fluoropyrimidine, oxaliplatin, and irinotecan-containing regimen.

Opdivo for unresectable or metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen; or
    • requested agent will be used in combination with ipilimumab and either: pemetrexed and carboplatin, pemetrexed and cisplatin, or paclitaxel and carboplatin; or
    • tumor has PD-L1 expression ≥ 1% and the requested agent is used in combination with ipilimumab.

Opdivo for metastatic squamous cell carcinoma of the esophagus (ESCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has received prior fluoropyrimidine-based and platinum-based chemotherapy.

Tecentriq for unresectable locally advanced or metastatic triple-negative breast cancer (TNBC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • PD-L1-stained tumor-infiltrating immune cells covering ≥ 1% of tumor area; and
  • requested agent will be used in combination with albumin-bound paclitaxel.

Tecentriq for hepatocellular carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with bevacizumab.

Tecentriq for unresectable or metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen; or
    • requested agent will be used in combination with Avastin (bevacizumab), paclitaxel, and carboplatin in the first-line setting for nonsquamous NSCLC; or 
    • tumor has PD-L1 expression ≥ 50%; or
    • requested agent will be used in combination with albumin-bound paclitaxel and carboplatin in the first-line setting for nonsquamous NSCLC.

Tecentriq for extensive-stage (ES) SCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has extensive stage disease; and
  • requested agent will be used in combination with carboplatin and etoposide.

Tecentriq for UC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • if treatment-naïve, PD-L1-stained tumor-infiltrating immune cells covering ≥ 5% of tumor area, or member is not a candidate for any platinum-containing chemotherapy due to poor performance status; and
  • one of the following:
    • inadequate response or adverse reaction to a regimen containing cisplatin; or
    • contraindication to cisplatin and inadequate response or adverse reaction to a regimen containing gemcitabine and carboplatin; or
    • contraindication to cisplatin and contraindication to gemcitabine or carboplatin.

Tecentriq for unresectable or metastatic melanoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF V600E or V600K mutation; and
  • documentation that the requested agent will be used in combination with Cotellic (cobimetinib) and Zelboraf (vemurafenib); and
  • inadequate response or adverse reaction to one of the following or contraindication to all of the following: 
    • Tafinlar (dabrafenib) + Mekinist (trametinib); or
    • Cotellic (cobimetinib) + Zelboraf (vemurafenib); or
    • Braftovi (encorafenib) + Mektovi (binimetinib).

Lynparza for germline BRCA (gBRCA)-mutated breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is HER-2 negative; and
  • request is within quantity limit of four tablets/day.

Lynparza for Homologous recombination repair (HRR) gene-mutated metastatic castration-resistant prostate cancer (mCRPC)

• Documentation of the following is required: 
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has deleterious or suspected deleterious germline or somatic HRR gene mutation; and
  • inadequate response or adverse reaction to one of the following or contraindication to all of the following: 
    • Xtandi (enzalutamide); or
    • Yonsa (abiraterone); or
    • Zytiga (abiraterone); and
  • request is within quantity limit of four tablets/day.

Lynparza for ovarian cancer

• For progressive disease, documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has confirmed or suspected deleterious BRCA germline mutation; and
  • one of the following:
    • inadequate response or adverse reaction to at least three prior chemotherapy regimens; or
    • contraindication to the use of recommended chemotherapy regimens; and
  • request is within quantity limit of four tablets/day.

• For maintenance therapy as monotherapy, documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has deleterious or suspected deleterious germline or somatic BRCA-mutated (gBRCAm or sBRCAm) and has completed one line of platinum-based chemotherapy; or
    • member has completed two or more lines of platinum-based chemotherapy; or
    • contraindication to the use of recommended chemotherapy regimens; and
  • member has achieved a partial or complete response requiring maintenance therapy; and
  • request is within quantity limit of four tablets/day.

• For maintenance therapy as combination therapy, documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is homologous recombination deficiency (HRD) positive status defined by either a deleterious or suspected deleterious BRCA mutation and/or genomic instability; and 
  • member has achieved a partial or complete response on Avastin (bevacizumab) requiring maintenance therapy; and
  • requested agent will be used in combination with Avastin (bevacizumab); and
  • request is within quantity limit of four tablets/day.

Lynparza for pancreatic adenocarcinoma (maintenance therapy)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has deleterious or suspected deleterious gBRCA mutation; and
  • member has disease which has not progressed on at least 16 weeks of a first-line platinum-based chemotherapy regimen; and
  • request is within quantity limit of four tablets/day.

Rubraca for BRCA-mutated metastatic castration-resistant prostate cancer (mCRPC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has deleterious (germline and/or somatic) BRCA mutation; and 
  • inadequate response or adverse reaction to one of the following or contraindication to all of the following:
    • Xtandi (enzalutamide); or
    • Yonsa (abiraterone); or
    • Zytiga (abiraterone); and
  • inadequate response, adverse reaction, or contraindication to taxane-based chemotherapy; and
  • request is within quantity limit of four units/day.

Rubraca for ovarian cancer

• For progressive disease, documentation of the following is required:
  • appropriate diagnosis; and 
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has confirmed deleterious BRCA germline mutation; and
  • one of the following:
    • inadequate response or adverse reaction to at least two prior chemotherapy regimens; or
    • contraindication to the use of recommended chemotherapy regimens; and
  • request is within quantity limit of four units/day.
• For maintenance therapy, documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has completed two or more lines of platinum-based chemotherapy; or
    • contraindication to the use of recommended chemotherapy regimens; and
  • member has achieved a partial or complete response requiring maintenance therapy; and
  • request is within quantity limit of four tablets/day.

Talzenna

• Documentation of the following is required:
  • diagnosis of germline BRCA-mutated breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is HER-2 negative; and
  • request is within quantity limit of one capsule/day.

Zejula for ovarian cancer

• For maintenance therapy, documentation of the following is required:
  • appropriate diagnosis; and 
  • appropriate dosing; and
  • prescriber is an oncologist; and
  • one of the following:
    • member has completed one or more lines of platinum-based chemotherapy; or
    • contraindication to the use of recommended chemotherapy; and
  • member has achieved a partial or complete response requiring maintenance therapy; and
  • request is within quantity limit of three units/day.

• For progressive disease, documentation of the following is required:
  • appropriate diagnosis; and 
  • appropriate dosing; and
  • prescriber is an oncologist; and
  • one of the following:
    • member has completed three or more lines of platinum-based chemotherapy; or
    • contraindication to the use of recommended chemotherapy; and 
  • cancer is homologous recombination deficient (HRD) positive status as defined by either a deleterious or suspected deleterious BRCA mutation, or genomic instability and who have progressed more than six months after response to the last platinum-based chemotherapy; and
  • request is within quantity limit of three units/day. 

Kyprolis

• Documentation of the following is required for monotherapy:
  • diagnosis of multiple myeloma; and
  • appropriate dosing; and
  • prescriber is an oncologist or hematologist; and
  • inadequate response, adverse reaction or contraindication to bortezomib; and
  • inadequate response or adverse reaction to one of the following immunomodulatory agents or contraindication to all of the following immunomodulatory agents:
    • Revlimid (lenalidomide); or
    • Thalomid (thalidomide); or
    • Pomalyst (pomalidomide).

• Documentation of the following is required for combination therapy:
  • diagnosis of multiple myeloma; and
  • appropriate dosing; and
  • prescriber is an oncologist or hematologist; and
  • inadequate response or adverse reaction to at least one prior chemotherapy regimen for the requested indication; and
  • one of the following:
    • documentation that the agent will be used in combination with Revlimid (lenalidomide) and dexamethasone; or
    • documentation that the agent will be used in combination with dexamethasone.

Ninlaro

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • appropriate dosing; and
  • prescriber is an oncologist or hematologist; and
  • documentation that the agent will be used in combination with Revlimid (lenalidomide) and dexamethasone; and
  • request is within quantity limit of 3 capsules/28 days.

Etopophos

• Documentation of the following is required:
  • diagnosis of small cell lung cancer or testicular cancer; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • clinical rationale for use of the requested agent instead of an etoposide product available without prior authorization.

Onivyde

• Documentation of the following is required:
  • diagnosis of metastatic adenocarcinoma of the pancreas; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • requested agent will be used in combination with fluorouracil and leucovorin; and
  • inadequate response, adverse reaction, or contraindication to the use of a gemcitabine- or fluoropyrimidine-based chemotherapy regimen.

 Alecensa

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer that is anaplastic lymphoma kinase (ALK)-positive; and
  • request is within quantity limit of eight units/day.

Alunbrig

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is anaplastic lymphoma kinase (ALK)-positive; and
  • one of the following:
    • if the request is for the 30 mg tablet, quantity limit of two units/day; or
    • if the request is for the 90 mg or 180 mg tablet, or the 90 mg-180 mg tablet pack, quantity limit of one unit/day.

Ayvakit

• Documentation of the following is required:
  • diagnosis of unresectable or metastatic GIST; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has disease harboring a PDGFRA exon 18 mutation (including PDGFRA D842V mutations); and
  • request is within quantity limit of one unit/day.

Bosulif

• Documentation of the following is required:
  • diagnosis of CML; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has chronic phase Philadelphia chromosome-positive (Ph+) CML; or
    • inadequate response or adverse reaction to one prior therapy for CML or contraindication to all other therapies for CML.

Brukinsa

• Documentation of the following is required:  
  • diagnosis of MCL; and
  • member ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of MCL.

Cabometyx for advanced renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has poor/intermediate risk and the request is for first-line treatment of clear cell histology; or
    • member has favorable risk and clear cell histology and inadequate response or adverse reaction to one or contraindication to both of the following: Votrient (pazopanib), Sutent (sunitinib); or
    • member has clear cell histology and has received a previous treatment in the metastatic setting; or
    • member has non-clear cell histology and member has an inadequate response, adverse reaction, or contraindication to Sutent (sunitinib); and
  • request is within quantity limit of one unit/day.

Cabometyx for unresectable HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has Child-Pugh Class A; and
  • inadequate response, adverse reaction, or contraindication to Nexavar (sorafenib); and
  • request is within quantity limit of one unit/day.

Calquence for CLL/SLL

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member is treatment naive and one of the following:
      • requested agent will be used in combination with obinutuzumab; or
      • clinical rationale for use of the requested agent as monotherapy; or
    • member has relapsed disease, refractory disease, or prior therapy for the treatment of CLL/SLL.

Calquence for MCL

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of MCL.

Caprelsa

• Documentation of the following is required:
  • diagnosis of symptomatic or progressive medullary thyroid cancer; and
  • one of the following:
    • request is within quantity limit of one unit/day for 300 mg tablets or two units/day for 100 mg tablets; or
    • medical necessity for exceeding quantity limit of one unit/day for 300 mg tablets or two units/day for 100 mg tablets.

Cometriq

• Documentation of the following is required:
  • diagnosis of symptomatic or progressive medullary thyroid cancer; and
  • one of the following
    • requested dose does not exceed 140 mg/day; or
    • medical necessity for exceeding the 140 mg/day dose.

erlotinib for advanced or metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has epidermal growth factor receptor (EGFR) mutations; and
  • request is within quantity limit of one unit/day.

erlotinib for advanced or metastatic pancreatic cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member will be using the requested agent in combination with gemcitabine; and
  • request is within quantity limit of one unit/day.

Iclusig for ALL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one of the following or contraindication to all of the following: imatinib, Sprycel (dasatinib), Tasigna (nilotinib).

Iclusig for CML

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to two of the following or a contraindication to all of the following: Bosulif (bosutinib), imatinib, Sprycel (dasatinib), Tasigna (nilotinib); or
    • confirmed T315I mutation.

Imbruvica for chronic graft versus host disease (cGVHD)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of cGVHD with at least one systemic therapy.

Imbruvica for CLL, SLL, CLL/SLL with 17p deletion, and Waldenstrom's macroglobulinemia (WM)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing.

Imbruvica for MCL and marginal zone lymphoma (MZL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of MCL or MZL with at least one systemic therapy.

Inlyta

• Documentation of the following is required:
  • diagnosis of advanced renal cell carcinoma; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Inrebic

• Documentation of the following is required:
  • diagnosis of intermediate or high-risk primary myelofibrosis (PMF), post-polycythemia vera myelofibrosis (post-PV MF), or post-essential thrombocythemia myelofibrosis (post-ET MF); and
  • member is ≥ 18 years of age; and
  • inadequate response, adverse reaction, or contraindication to Jakafi (ruxolitinib); and
  • request is within quantity limit of four units/day.

Iressa

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has epidermal growth factor receptor (EGFR) mutations; and
  • request is within quantity limit of one unit/day.

Nexavar

• Documentation of the following is required:
  • diagnosis of advanced renal cell carcinoma, DTC, or unresectable HCC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • request is within quantity limit of four units/day.

Rydapt for FLT3-mutated acute myeloid leukemia (AML)

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • for induction therapy, requested agent will be used in combination with cytarabine and daunorubicin; or
    • for consolidation therapy, requested agent will be used in combination with cytarabine.

Rydapt for aggressive systemic mastocytosis (SM), SM with associated hematological neoplasm, and mast cell leukemia

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • member has aggressive SM without the D816V c-Kit mutation (as determined by an FDA-approved test) or with c-Kit mutation status unknown; and
      • inadequate response, adverse reaction, or contraindication to imatinib; or
    • D816V c-Kit mutation positive (as determined by an FDA-approved test).

Sutent for advanced renal cell carcinoma and advanced pancreatic neuroendocrine tumors (PNET)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • request is within quantity limit of one unit/day.
   

Sutent for GIST

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to imatinib; and
  • request is within quantity limit of one unit/day.

Sutent for renal cell carcinoma (adjuvant setting)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor is clear cell histology; and
  • request is within quantity limit of one unit/day.
   

Tukysa 

• Documentation of the following is required:
  • diagnosis of advanced unresectable or metastatic HER2-positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with trastuzumab and capecitabine; and
  • inadequate response or adverse reaction to one anti-HER2-based regimen; and
  • request is within quantity limit of four units/day.

Turalio

• Documentation of the following is required:
  • diagnosis of tenosynovial giant cell tumor; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is not a candidate for surgery.

Votrient for advanced renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • request is within quantity limit of four units/day.

Votrient for soft tissue sarcoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to prior chemotherapy; and
  • request is within quantity limit of four units/day.

Xalkori

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is anaplastic lymphoma kinase (ALK)-positive; and
  • request is within quantity limit of two units/day.

Xospata

• Documentation of the following is required:  
  • diagnosis of FLT3-mutated AML; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has received at least one line of treatment; or
    • member has relapsed or refractory disease; and
  • request is within quantity limit of three units/day.

Zykadia

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is anaplastic lymphoma kinase (ALK)-positive; and
  • request is within quantity limit of three units/day.

Marqibo

• Documentation of the following is required:
  • diagnosis of Philadelphia chromosome negative ALL; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • medical records documenting trials with two previous chemotherapy regimens.      

Afinitor Disperz and everolimus 2.5 mg, 5 mg, 7.5 mg, 10 mg for treatment-resistant epilepsy associated with tuberous sclerosis complex (TSC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is a neurologist or consult notes from a neurologist are provided; and
  • inadequate response to combination therapy with at least two anticonvulsants or contraindication to all other anticonvulsants; and
  • requested agent will be used as adjunctive therapy with at least one anticonvulsant agent; and
  • request is within quantity limit of one unit/day.

Afinitor Disperz for subependymal giant cell astrocytoma (SEGA) with TSC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • request is within quantity limit of one unit/day.

everolimus 2.5 mg, 5 mg, 7.5 mg, 10 mg for advanced hormone receptor-positive, HER2-negative breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested regimen includes exemestane, fulvestrant, or tamoxifen; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: anastrozole, letrozole, tamoxifen, toremifene, exemestane; and
  • request is within quantity limit of one unit/day.

everolimus 2.5 mg, 5 mg, 7.5 mg, 10 mg for advanced renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • tumor is non-clear cell histology; or
    • tumor is clear cell histology and inadequate response or adverse reaction to one or contraindication to all first-line therapies; and
  • request is within quantity limit of one unit/day.

everolimus 2.5 mg, 5 mg, 7.5 mg, 10 mg for renal angiomyolipoma with TSC, advanced PNET, advanced neuroendocrine tumors (NET) of gastrointestinal or lung origin, and SEGA with TSC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • request is within quantity limit of one unit/day.