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 given concurrently 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 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 given concurrently 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 given concurrently 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 given concurrently with carboplatin and paclitaxel.

Zaltrap

• Documentation of the following is required:
  • diagnosis of metastatic colorectal cancer; and
  • prescriber is a specialist; and
  • appropriate dosing; and
  • requested agent will be given concurrently 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; 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 GnRH analog; or
    • member had a bilateral orchiectomy.

Erleada and Nubeqa

• Documentation of the following is required:
  • diagnosis of non-metastatic castration-resistant prostate cancer (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 gonadotropin-releasing hormone (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 gonadotropin-releasing hormone (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.

 

    

 

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 in postmenopausal women

• Documentation of the following is required:
  • diagnosis of hormone receptor-positive metastatic breast cancer with disease progression following antiestrogen therapy; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to one aromatase inhibitor; or
    • inadequate response, adverse reaction, or contraindication to tamoxifen or toremifene; or
    • member is unable to take oral medications.

fulvestrant in premenopausal women

• Documentation of the following is required:
  • diagnosis of hormone receptor-positive metastatic breast cancer with disease progression following antiestrogen therapy; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with ovarian ablation/suppression; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to one aromatase inhibitor; or
    • inadequate response, adverse reaction, or contraindication to tamoxifen or toremifene; or
    • member is unable to take oral medications.

 

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 30 units/30 days; 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

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • quantity limit of 21 capsules for a 28 day supply; 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).

 

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 28 capsules for a 28 day supply; 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. ^†

 

     

 

                                                                                 

 

 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 240 units/30 days.

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.

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 60 units for a 30 day supply; or
    • if the request is for the 90 mg or 180 mg tablet, or the 90 mg-180 mg tablet pack, quantity limit of 30 units for a 30 day supply.

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

• 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 Mektovi (binimetinib).

Calquence

• 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.

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).

Ibrance for HER2-negative, ER-positive breast cancer in women

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • concurrent therapy with letrozole and member is postmenopausal; or
    • concurrent therapy with fulvestrant and one of the following:
      • inadequate response, adverse reaction, or contraindication to at least one aromatase inhibitor and member is postmenopausal; or
      • inadequate response, adverse reaction, or contraindication to tamoxifen or toremifene and member is premenopausal or perimenopausal.

Ibrance for HER2-negative, ER-positive breast cancer in men

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • concurrent therapy with an aromatase inhibitor.

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:
    • member is postmenopausal and the requested agent will be used in combination with anastrozole, exemestane, fulvestrant, or letrozole; or
    • member is pre/perimenopausal, received ovarian ablation or suppression, and the requested agent will be used in combination with anastrozole, exemestane, or letrozole.

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.

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
  • request is within quantity limit of 90 units/30 days; and
  • one of the following:
    • tumor is non-clear cell histology and inadequate response or adverse reaction to one or contraindication to all systemic therapies; or
    • all of the following:
      • tumor is clear cell histology; and
      • inadequate response or adverse reaction to one or contraindication to all first-line therapies; and
      • inadequate response or adverse reaction to one or contraindication to both of the following: cabozantinib, nivolumab.

Lenvima for differentiated thyroid cancer (DTC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • request is within quantity limit of 90 units/30 days.

Lenvima for unresectable hepatocellular carcinoma (HCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • request is within quantity limit of 90 units/30 days.

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 30 units/30 days.

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

• Documentation of the following is required:
  • diagnosis of extended adjuvant treatment of early stage HER2-postive breast cancer; 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 180 units/30 days.

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.

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.

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; and
  • request is within quantity limit of 56 units/28 days.

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); and
  • request is within quantity limit of 112 units/28 days.

Stivarga for gastrointestinal stromal tumor (GIST)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is a specialist; and
  • appropriate dose; and
  • previous trial with or a contraindication to both of the following: imatinib and Sutent (sunitinib).

Stivarga for HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is a specialist; and
  • appropriate dose; 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 a specialist; and
  • appropriate dose; and
  • a previous trial with one of the following regimens or a contraindication to all of the following regimens: CAPEOX, FOLFIRI, FOLFOX, FOLFOXIRI; and
  • if KRAS/NRAS wild-type cancer is present, a previous trial with one or a contraindication to both of the following: Erbitux (cetuximab), Vectibix (panitumumab).

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 30 units/30 days; 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; and
  • one of the following:
    • concurrent therapy with an aromatase inhibitor; or
    • concurrent therapy with fulvestrant when disease has progressed after hormonal therapy; or
    • monotherapy when disease has progressed after both hormonal therapy and chemotherapy; and
  • request is within quantity limit of 60 tablets/30 days.

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 30 units/30 days.

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 84 units/28 days.

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.

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 90 units/30 days.

 

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 30 units/30 days; 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
  • a previous trial with one or more of the following regimens or a contraindication to all of the following regimens: CAPEOX, FOLFOX, FOLFIRI, FOLFOXIRI; and
  • if KRAS/NRAS wild-type cancer is present, a previous trial with one or a 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.

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 60 units/30 days; 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
      • 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.

Besponsa and Blincyto

• Documentation of the following is required:
  • diagnosis of ALL; and
  • if the request is for Besponsa, 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.

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 given concurrently 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 given concurrently with docetaxel; and
  • inadequate response, adverse reaction, or contraindication to a platinum-containing chemotherapy regimen.

Darzalex

• 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
    • 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 and rationale for use of this combination instead of Darzalex (daratumumab) with Revlimid (lenalidomide) and dexamethasone; or
    • 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
  • 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.

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.

Lartruvo

• Documentation of the following is required:
  • diagnosis of soft tissue sarcoma; and
  • appropriate dosing and frequency; and
  • member is ≥ 18 years of age; and
  • member is not a candidate for surgery and/or radiation therapy; and
  • requested agent will be used in combination with doxorubicin for the first eight cycles of treatment.

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.

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 and Rituxan Hycela 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 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 for Wegener's Granulomatosis 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 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.

 

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 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); and
  • clinical rationale for use instead of Keytruda (pembrolizumab).

Bavencio, Imfinzi, and Opdivo for urothelial carcinoma (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.

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.

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 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 for Hodgkin Lymphoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has relapsed or has received three or more lines of prior therapy, one of which was brentuximab.

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; and
  • disease progression following at least one prior regimen FDA-approved to treat the indication.

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 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 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).

Keytruda 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 two lines of therapies, one of which is platinum-based.

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.

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

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

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 B7; and
  • inadequate response, adverse reaction, or contraindication to Nexavar (sorafenib).

Opdivo for recurrent or metastatic 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.

Opdivo for Hodgkin Lymphoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • disease progression after ASCT; and
  • member received post-transplant brentuximab.

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; or
    • contraindication to a fluoropyrimidine, oxaliplatin, and irinotecan.

Opdivo for unresectable or metastatic NSCLC

• 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 metastatic 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.

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 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.

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.

 

Lynparza for germline BRCA-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 120 tablets/30 days.

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 120 tablets/30 days.

 

• 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 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 120 tablets/30 days.

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 120 units/30 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 120 tablets/30 days.

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 30 capsules/30 days.

Zejula

• Documentation of the following is required:
  • diagnosis of ovarian cancer; and 
  • appropriate dosing; and
  • prescriber is an oncologist; and
  • one of the following:
    • member has completed two 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 90 units/30 days.

 

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.

 

    

 

       

 

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.

 

Bosulif

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

Cabometyx for advanced renal cell 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 or contraindication to both of the following: Votrient (pazopanib), Sutent (sunitinib); and
  • request is within quantity limit of 30 units/30 days.

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 30 units/30 days.

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 30 units/30 days for 300 mg tablets or 60 units/30 days for 100 mg tablets; or
    • medical necessity for exceeding quantity limit of 30 units/30 days for 300 mg tablets or 60 units/30 days 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 30 units/30 days.

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 30 units/30 days.

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 30 units/30 days.

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 120 units/30 days.

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 30 units/30 days.

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 60 units/30 days.

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 60 units/30 days.

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 60 units/30 days.

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 120 units/30 days.

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 30 units/30 days.
   

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 30 units/30 days.

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 30 units/30 days.
   

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 120 units/30 days.

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 120 units/30 days.

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 60 units/30 days.

 

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 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 30 units/30 days.

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 30 units/30 days.

everolimus 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; and
  • inadequate response or adverse reaction to one or contraindication to both of the following: anastrozole, letrozole; and
  • request is within quantity limit of 30 units/30 days.

everolimus 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 30 units/30 days.

everolimus 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 30 units/30 days.