Oncologic Therapies

Abecma^® (Idecabtagene Vicleucel) Approval Criteria [Multiple Myeloma Diagnosis]:

• Diagnosis of relapsed or refractory multiple myeloma (RRMM):
  • Member has received ≥4 prior lines of therapy, including an immunomodulatory agent, a proteasome inhibitor (PI), and an anti-CD38 monoclonal antibody; and
    • Induction with or without autologous hematopoietic stem cell transplant and with or without maintenance therapy is considered a single regimen; and
    • Must have undergone ≥2 consecutive cycles of treatment for each regimen unless progressive disease was seen after 1 cycle; and
  • Member must have measurable disease, including at least 1 of the following:
    • Serum M-protein ≥0.5g/dL; or
    • Urine M-protein ≥200mg/24hr; or
    • Serum free light chain (FLC) assay: involved FLC ≥10mg/dL (100mg/L); or
    • Bone marrow plasma cells >30% of total bone marrow cells; and
  • Member must not have any central nervous system involvement with multiple myeloma.

Afinitor® (Everolimus) Approval Criteria (Breast Cancer Diagnosis):

• Diagnosis of advanced breast cancer; AND  
• Negative expression of Human Epidermal Receptor Type 2 (HER2); AND
• Hormone receptor-positive (ER positive); AND
• Used in combination with exemestane, fulvestrant, or tamoxifen; AND
• Member must have failed treatment with, have a contraindication to, or be intolerant to letrozole or anastrozole.

Afinitor® (Everolimus) Approval Criteria [Neuroendocrine Tumors of Pancreatic Origin (PNET) or Neuroendocirne Tumors (NET) of Gastrointestinal or Lung OriginDiagnosis]:

• Diagnosis of unresectable, locally advanced, or metastatic neuroendocrine tumors of pancreatic origin (PNET) gastrointestinal, or lung (NET) origin; AND
• Progressive disease from a previous treatment.
• Authorizations will be for the duration of three months. Reauthorization may be granted if the patient does not show evidence of progressive disease while on everolimus therapy.

Afinitor® (Everolimus) Approval Criteria (Renal Cell Carcinoma Diagnosis):

• Diagnosis of advanced renal cell carcinoma; AND  
• Failure of treatment with sunitinib or sorafenib.
• Everolimus may also be approved to be used in combination with lenvatinib for advanced renal cell carcinoma.
• Authorizations will be for the duration of three months. Reauthorization may be granted if the patient does not show evidence of progressive disease while on everolimus therapy

Afinitor® (Everolimus) Approval Criteria [Renal Angiomyolipoma and Tuberous Sclerosis Complex (TSC) Diagnosis]:

• Diagnosis of renal angiomyolipoma and tuberous sclerosis complex (TSC); and
• Not requiring immediate surgery; AND
• Used in pediatric and adult patients with age ≥ 1 year.

Afinitor® (Everolimus) Approval Criteria [Subependymal Giant Cell Astrocytoma (SEGA) with Tuberous Sclerosis Complex (TSC) Diagnosis]:

• Diagnosis of subependymal giant cell astrocytoma (SEGA) with tuberous sclerosis complex (TSC); AND
• Requires therapeutic intervention but cannot be curatively resected.

Afinitor® (Everolimus) Approval Criteria [Tuberous Sclerosis Complex (TSC)-Associated Partial-Onset Seizures Diagnosis]:

• An FDA approved diagnosis of TSC-associated partial-onset seizures; AND
• Initial prescription must be written by a neurologist or neuro-oncologist; AND
• Member must have failed therapy with at least three other medications commonly used for seizures; AND
• Afinitor® must be used as adjunctive treatment; AND
• The member must not be taking any P-gp and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir, clarithromycin) concurrently with Afinitor®; AND
• The member must not be taking St. John’s wort concurrently with Afinitor®; AND
• The prescriber must verify that Afinitor® trough levels and adverse reactions (e.g., non-infectious pneumonitis, stomatitis, hyperglycemia, dyslipidemia, thrombocytopenia, neutropenia, febrile neutropenia) will be monitored, and dosing changes or discontinuations will correspond with recommendations in the drug labeling; AND
• Verification from the prescriber that female members will use contraception while receiving Afinitor® therapy and for eight weeks after the last dose of Afinitor® and that male members with female partners of reproductive potential will use contraception while receiving Afinitor® therapy and for four weeks after the last dose of Afinitor®; AND
• The member’s recent body surface area (BSA) must be provided on the prior authorization request in order to authorize the appropriate amount of drug required according to package labeling. 
• Initial approvals will be for the duration of three months. For continuation, the prescriber must include information regarding improved response/effectiveness of the medication. 

Prior Authorization Form - Afinitor

Alecensa® (Alectinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• A diagnosis of recurrent or metastatic NSCLC; AND
• Anaplastic lymphoma kinase (ALK) positivity; AND
• Alectinib must be used as a single-agent only; AND
• Alectinib may be used in first-line or recurrent setting.

Prior Authorization Form - Alecensa

Aliqopa™ (Copanlisib) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]:  

• A diagnosis of relapsed/refractory FL; AND
• Member must have failed at least 2 prior systemic therapies.  

Prior Authorization Form - Aliqopa

Alunbrig™ (brigatinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• A diagnosis of metastatic NSCLC; AND
• Anaplastic lymphoma kinase (ALK) positivity.

 Prior Authorization Form - Alunbrig

Alymsys^® (Bevacizumab-maly) and Mvasi^® (Bevacizumab-awwb) Approval Criteria :

• A patient-specific, clinically significant reason why the member cannot use Avastin^® (bevacizumab) or Zirabev^® (bevacizumab-bvzr), which is are available without prior authorization, must be provided. Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products.

Mvasi - Prior Authorization Form

Arzerra® (Ofatumumab) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:  

• As first-line treatment of CLL in combination with chlorambucil or bendamustine; OR
• For relapsed or refractory disease as a single-agent or in combination with fludarabine and cyclophosphamide; OR
• As maintenance therapy as second-line extended dosing following complete or partial response to relapsed or refractory therapy (maximum 2 years).  

Arzerra® (Ofatumumab) Approval Criteria [Waldenström’s Macroglobulinemia (WM)/Lymphoplasmacytic Lymphoma Diagnosis]:

• For previously treated disease that does not respond to primary therapy or for progressive or relapsed disease; AND
• As a single-agent or combination therapy; AND
• Member is rituximab-intolerant. 

 Prior Authorization - Arzerra

Asparlas™ (Calaspargase Pegol-mknl) and Oncaspar^® (Pegaspargase) Approval Criteria [Acute Lymphoblastic Leukemia (ALL) Diagnosis]:

• For Asparlas^®, a patient-specific, clinically significant reason why the member cannot use pegaspargase must be provided; AND
• For Asparlas^®, member must be 1 month to 21 years of age. 
• Diagnosis of ALL; and
• Used as first-line therapy; or
• May be used to treat members with a hypersensitivity to native forms of L-asparaginase; or
• Used as systemic central nervous system (CNS)-directed therapy; or
• Used in relapsed/refractory disease; and
  • Philadelphia chromosome negative (Ph-); or
  • Philadelphia chromosome positive (Ph+); and
    • Refractory to tyrosine kinase inhibitor (TKI) therapy or used in conjunction with a TKI (if not previously used).   

Asparlas^® (Calaspargase Pegol-mknl) and Oncaspar^® (Pegaspargase) Approval Criteria [Extranodal NK/T-Cell Lymphoma Diagnosis]:

• For Asparlas^®, a patient-specific, clinically significant reason why the member cannot use Oncaspar^® (pegaspargase) must be provided; and
• For Asparlas^®, member must be 1 month to 21 years of age; and
• Diagnosis of NK/T-Cell lymphoma; and
• Member has nasal disease; and
  • Used as induction therapy; or
  • Used as additional therapy in members with a positive biopsy following a partial or no response to induction therapy. 

Prior Authorization Form - Asparlas

Ayvakit™ (Avapritinib) Approval Criteria [Gastrointestinal Stromal Tumor (GIST) Diagnosis]:

• A diagnosis of unresectable or metastatic GIST in adult members; AND
• Member has a PDGFRA exon 18 mutation (including PDGFRA D842V mutations).  

Prior Authorization Form - Ayvakit

Ayvakit™ (Avapritinib) Approval Criteria [Systemic Mastocytosis Diagnosis]:

• Diagnosis of advanced systemic mastocytosis, including members with aggressive systemic mastocytosis, systemic mastocytosis with an associated hematologic neoplasm, OR mast cell leukemia; and
• Platelet count ≥50 x 10⁹/L.

Azedra® (Iobenguane I-131) Approval Criteria [Pheochromocytoma or Paraganglioma (PPGL) Diagnosis]:

• Adult and pediatric members 12 years of age and older; AND
• Iobenguane scan positive; AND
• Unresectable, locally advanced or metastatic pheochromocytoma or PPGL requiring systemic anticancer therapy. 

Prior Authorization Form - Azedra

Balversa™ (Erdafitinib) Approval Criteria [Urothelial Carcinoma Diagnosis]:   

• A diagnosis of locally advanced or metastatic urothelial carcinoma; AND  
• Tumor positive for FGFR2 or FGFR3 genetic mutation; AND  
• Use in second-line or greater treatments including: 
  • Following at least 1 line of platinum-containing chemotherapy; AND
  • Within 12 months of neoadjuvant or adjuvant platinum-containing chemotherapy 

Prior Authorization Form - Balversa

Bavencio® (Avelumab) Approval Criteria [Merkel Cell Carcinoma (MCC) Diagnosis]:

• A diagnosis of metastatic MCC; AND
• Member must be 12 years of age or older. 

Bavencio® (Avelumab) Approval Criteria [Renal Cell Carcinoma (RCC) Diagnosis]:

• Diagnosis of advanced RCC; AND
• Must be used as first-line treatment; AND
• Must be used in combination with axitinib.

Bavencio® (Avelumab) Approval Criteria [Urothelial Carcinoma Diagnosis]:

• A diagnosis of locally advanced or metastatic urothelial carcinoma; AND
• Disease has progressed during or following platinum-containing chemotherapy or within 12 months of neoadjuvant or adjuvant platinum-containing chemotherapy; or
• Used as maintenance therapy for members not progressing on the first-line platinum-containing regimen.

Prior Authorization Form- Bavencio 

Besponsa® (Inotuzumab Ozogamicin) Approval Criteria:   

• Besponsa® must be used as a single-agent only; AND  
• Member must have one of the following:
  • Relapsed/refractory Philadelphia chromosome negative (Ph-) acute lymphoblastic leukemia (ALL); OR  
  • Relapsed/refractory Philadelphia chromosome positive (Ph+) ALL who are intolerant/refractory to two or more Tyrosine Kinase Inhibitors (TKIs).  

Prior Authorization Form - Besponsa

Blenrep (Belantamab Mafodotin-blmf) Approval Criteria [Multiple Myeloma Diagnosis]: 

• Diagnosis of relapsed or refractory multiple myeloma (RRMM) in adults; and
• Member has received ≥4 prior therapies including an anti-CD38 monoclonal antibody, a proteasome inhibitor (PI), and an immunomodulatory agent; and
• Prescriber must verify the member will receive eye exams, including visual acuity and slit lamp ophthalmic examinations, with each cycle (every 3 weeks). 

bosutinib (Bosulif®) Approval Criteria [Chronic Myeloid Leukemia (CML) Diagnosis]:  

• Patients with chronic, accelerated, or blast phase CML; AND
• Newly diagnosed or resistant/intolerant to other tyrosine kinase inhibitors (TKIs).

bosutinib (Bosulif®) Approval Criteria [Philadelphia Chromosome Positive (Ph+) Acute Lymphoblastic Leukemia (ALL) Diagnosis]:

• Bosulif® may be authorized for relapsed/refractory ALL either as:
  • Single-agent; OR
  • In combination with an induction regimen not previously given; AND 
• Bosulif® must be only used in patients with E255K/V, F317L/VI/C, F359V/C/I, T315A, or Y253H mutations. 

Prior Authorization Form - Bosulif

Braftovi® (Encorafenib) Approval Criteria [Melanoma Diagnosis]:

• Diagnosis of unresectable or metastatic melanoma; AND
• BRAF V600E or V600K mutation; AND
• Used in combination with binimetinib.

• Diagnosis of advanced or metastatic CRC; and
• BRAF V600E mutation positive; and
• Used in combination with cetuximab or panitumumab; and
• Disease must have progressed following adjuvant therapy within 12 months; or
• Used following progression of any line of metastatic therapy.

Prior Authorization Form - Braftovi®

Breyanzi^® (Lisocabtagene Maraleucel) Approval Criteria [Lymphoma Diagnosis]:

• Diagnosis of large B-cell lymphoma; and
• Relapsed or refractory disease; and
• Member must have received at least 2 lines of systemic therapy; and
• Health care facilities must be on the certified list to administer chimeric antigen receptor (CAR) T-cells and must be trained in the management of cytokine release syndrome (CRS), neurologic toxicities, and comply with the risk evaluation and mitigation strategy (REMS) requirements; and
• A patient-specific, clinically significant reason why Yescarta^® (axicabtagene) or Kymriah^® (tisagenlecleucel) is not appropriate for the member must be provided. 

Brukinsa™ (Zanubrutinib) Approval Criteria [Mantle Cell Lymphoma (MCL) Diagnosis]: 

• Adult members with a diagnosis of MCL; AND
• Member must have received at least 1 prior therapy.   

Brukinsa^® (Zanubrutinib) Approval Criteria [Marginal Zone Lymphoma (MZL) Diagnosis]:

• Diagnosis of MZL in adult members; and
• Member must have received at least 1 prior anti-CD20 monoclonal antibody-based therapy.

Brukinsa^® (Zanubrutinib) Approval Criteria [Waldenström’s Macroglobulinemia Diagnosis]:

• Diagnosis of Waldenström’s macroglobulinemia in adult members; and
• Used as primary or subsequent therapy.

Prior Authorization Form - Brukinsa

Bynfezia Pen™ (Octreotide) Approval Criteria [Metastatic Carcinoid Tumor or Vasoactive Intestinal Peptide-Secreting Tumors (VIPoma) Diagnosis]: 

• A diagnosis of advanced metastatic carcinoid tumor or VIPoma; AND
• Presence of severe diarrhea or flushing; AND
• A patient-specific, clinically significant reason why the member cannot use other available short-acting injectable formulations of octreotide must be provided.  

Bynfezia Pen™ (Octreotide) Approval Criteria [Acromegaly Diagnosis]:

• A diagnosis of acromegaly; AND
• Documentation of inadequate response to or cannot be treated with surgical resection, pituitary irradiation, and bromocriptine mesylate or cabergoline at maximally tolerated doses; AND
• A patient-specific, clinically significant reason why the member cannot use other available short-acting injectable formulations of octreotide must be provided. 

Prior Authorization Form

Cabometyx^® (Cabozantinib) Approval Criteria:

• For cabozantinib monotherapy:
  • Diagnosis of advanced renal cell carcinoma (RCC); OR
  • Diagnosis of advanced hepatocellular carcinoma (HCC); AND
    • Member has previously received sorafenib.
  • Diagnosis of locally advanced or metastatic differentiated thyroid cancer (DTC) in adults and pediatric members 12 years of age and older; AND
    • Disease has progressed following prior vascular endothelial growth factor (VEGF)-targeted therapy; AND
    • Disease is radioactive iodine-refractory or member is ineligible for radioactive iodine; OR
• For cabozantinib in combination with nivolumab:
  • Diagnosis of relapsed or surgically unresectable stage 4 disease in the initial treatment of members with advanced RCC; AND
  • Nivolumab, when used in combination with cabozantinib for RCC, will be approved for a maximum duration of 2 years.

Prior Authorization

Calquence® (Acalabrutinib) Approval Criteria [Mantle Cell Lymphoma (MCL) Diagnosis]:  

• As a single-agent. 

Calquence® (Acalabrutinib) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:

• As a single-agent.

Prior Authorization Form - Calquence

Camcevi™ (Leuprolide) Approval Criteria [Prostate Cancer Diagnosis]:

• Diagnosis of advanced prostate cancer; and
• A patient-specific, clinically significant reason why the member cannot use Eligard^® (leuprolide acetate), Firmagon^® (degarelix), and Lupron Depot^® (leuprolide acetate) must be provided [reason(s) must address each medication].

Camcevi™ PA Form

Copiktra™ (Duvelisib) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]: 

• A diagnosis of relapsed or refractory FL; AND
• Progression of disease following 2 or more lines of systemic therapy; AND
• Must be used as a single-agent.

Copiktra™ (Duvelisib) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:

• A diagnosis of relapsed or refractory CLL or SLL; AND
• Progression of disease following 2 or more lines of systemic therapy; AND
• Must be used as a single-agent.   

Prior Authorization Form

Cosela™ (Trilaciclib) Approval Criteria:

• Diagnosis of extensive-stage small cell lung cancer (ES-SCLC); and
• Member is undergoing myelosuppressive chemotherapy with 1 of the following:
  • Platinum (carboplatin or cisplatin) and etoposide-containing regimen; or
  • Topotecan-containing regimen.

Cosela™ PA Form

Cotellic® (Cobimetinib) Approval Criteria [Melanoma Diagnosis]:

• All of the following criteria must be met for approval: 
  • Diagnosis of unresectable or metastatic melanoma; AND
  • BRAF V600E or V600K mutation detected by an FDA-approved test; AND
    • Cobimetinib is not indicated for wild-type BRAF melanoma 
  • One of the following is met: 
    • Used as first-line therapy in combination with vemurafenib; OR
    • Used as second-line therapy or subsequent therapy with vemurafenib  

Prior Authorization Form - Cotellic

Cyramza® (Ramucirumab) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]: 

• Diagnosis of metastatic NSCLC; and
• First-line in combination with erlotinib; and
  • Epidermal growth factor receptor (EGFR) exon 19 deletion or exon 21 L858R mutation; or
• Subsequent therapy for metastatic disease; and
  •  In combination with docetaxel. 

Cyramza® (Ramucirumab) Approval Criteria [Colorectal Cancer Diagnosis]:

• A diagnosis of colorectal cancer; AND
• Subsequent therapy for metastatic disease after progression on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine; AND
• Ramucirumab must be used in combination with an irinotecan based regimen.

Cyramza® (Ramucirumab) Approval Criteria [Esophageal Cancer Diagnosis]:

• A diagnosis of unresectable, locally advanced, recurrent or metastatic esophageal or esophagogastic junction adenocarcinoma; AND
• Member must have a Karnofsky performance score greater than or equal to 60%; AND
• Ramucirumab must be used as a single-agent or in combination with paclitaxel.

Cyramza® (Ramucirumab) Approval Criteria [Gastric Cancer Diagnosis]:

• A diagnosis of gastric cancer; AND
• Member is not a surgical candidate or has unresectable, locally advanced, recurrent or metastatic disease; AND
• Member has a Karnofsky performance score of greater than or equal to 60%; AND
• Ramucirumab must be used as a single-agent or in combination with paclitaxel.   

Cyramza® (Ramucirumab) Approval Criteria [Hepatocellular Carcinoma (HCC) Diagnosis]:  

• A diagnosis of HCC; AND
• Used as second-line or greater therapy; AND
• Previously failed sorafenib; AND
• Has an alpha-fetoprotein concentration ≥400ng/mL; AND
• Used as a single-agent.

 Prior Authorization Form - Cyramza

Danyelza^® (Naxitamab-gqgk) Approval Criteria [Neuroblastoma Diagnosis]:

• Diagnosis of relapsed or refractory high-risk neuroblastoma in adult and pediatric members 1 year of age and older; and
• Disease in the bone or bone marrow demonstrating a partial response, minor response, or stable disease to prior therapy (i.e., no progressive disease following most recent therapy); and
• Must be given in combination with a granulocyte-macrophage colony-stimulating factor (GM-CSF) according to package labeling (GM-CSF dosed at 250mcg/m²/day daily starting 5 days prior to Danyelza^® therapy and 500mcg/m²/day daily on days 1 to 5 of Danyelza^® therapy); and
• Prescriber must agree to provide the member appropriate premedication for pain management and neuropathic pain (e.g., oral opioids, gabapentin); and
• Prescriber must agree to provide the member appropriate premedication for infusion-related reactions and nausea/vomiting including an intravenous (IV) corticosteroid, a histamine 1 (H₁) antagonist, an H₂ antagonist, acetaminophen, and an antiemetic.

Prior Authorization

Darzalex^® (Daratumumab) and Darzalex Faspro™ (Daratumumab/ Hyaluronidase-fihj) Approval Criteria [Light Chain Amyloidosis Diagnosis]:

• Relapsed/refractory light chain amyloidosis as a single agent; or
• Newly diagnosed light chain amyloidosis in combination with bortezomib, cyclophosphamide, and dexamethasone.

• Diagnosis of multiple myeloma; and
• Used in 1 of the following settings:
  • In combination with lenalidomide and dexamethasone as primary therapy in members who are ineligible for autologous stem cell transplant (ASCT) or in members who have received at least 1 prior therapy; or
  • In combination with bortezomib, melphalan, and prednisone as primary therapy in members who are ineligible for ASCT; or
  • In combination with bortezomib, thalidomide, and dexamethasone, or bortezomib, lenalidomide, and dexamethasone as primary therapy in members who are eligible for ASCT; or
  • After at least 1 prior therapy in combination with 1 of the following:
    •  i.      Dexamethasone and bortezomib; or
    • ii.     Carfilzomib and dexamethasone; or
    • iii.      Dexamethasone and lenalidomide; or
    • iv.      Cyclophosphamide, bortezomib, and dexamethasone; or
    •  v.     Pomalidomide and dexamethasone* [*previous therapy for this combination must include lenalidomide and a protease inhibitor (PI)]; or
    •  vi.      Selinexor and dexamethasone; or
  • In combination with lenalidomide and dexamethasone for members who are ineligible for ASCT or with cyclophosphamide, bortezomib, and dexamethasone as primary therapy or for disease relapse after 6 months following primary induction therapy with the same regimen; or
  • As a single-agent in members who have received ≥3 prior therapies, including a PI and an immunomodulatory agent, or who are double refractory to a PI and an immunomodulatory agent.

Darzalex/Darzalex Faspro - PA

Daurismo™ (Glasdegib) Approval Criteria [Acute Myeloid Leukemia (AML) Diagnosis]:  

• Newly diagnosed AML in members 75 years of age or older or in adult members who have significant comorbidities that preclude use of intensive chemotherapy [severe cardiac disease, ECOG performance status ≥2, or serum creatinine (SCr) >1.3]; AND
• In combination with low-dose cytarabine (LDAC).  

Daurismo™ (Glasdegib) Approval Criteria [Acute Myeloid Leukemia (AML) Diagnosis]:

• Newly diagnosed AML in members 75 years of age or older or in adult members who have significant comorbidities that preclude use of intensive chemotherapy [severe cardiac disease, ECOG performance status ≥2, or serum creatinine (SCr) >1.3]; AND
• In combination with low-dose cytarabine (LDAC).

Prior Authorization Form - Daurismo

Elzonris® (Tagraxofusp-erzs) Approval Criteria [Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) Diagnosis]:  

• Diagnosis of BPDCN; AND
• Member must be 2 years of age or older; AND
• Must be used as a single-agent.   

Prior Authorization Form - Elzonirs

Empliciti^® (Elotuzumab) Approval Criteria [Multiple Myeloma Diagnosis]:

• Diagnosis of previously treated multiple myeloma with relapsed or progressive disease; and
• Used in combination with 1 of the following regimens:
  • Lenalidomide and dexamethasone in members who have received 1 to 3 prior therapies; or
  • Bortezomib and dexamethasone; or
  • Pomalidomide and dexamethasone in members who have received ≥2 prior therapies, including an immunomodulatory agent and a proteasome inhibitor (PI).

Empliciti® PA Form

Enhertu^® (Fam-Trastuzumab Deruxtecan-nxki) Approval Criteria [Colorectal Cancer (CRC) Diagnosis]:

• Diagnosis of advanced or metastatic disease; AND
• Disease has progressed on prior therapy; AND
• Human epidermal receptor type 2 (HER2) amplified disease; AND
• RAS and BRAF mutation negative; AND
• Used as a single agent.

Enhertu® (Fam-Trastuzumab Deruxtecan-nxki) Approval Criteria [Breast Cancer Diagnosis]:

• Adult members with unresectable or metastatic disease; AND
  • For human epidermal growth factor receptor 2 (HER2)-positive disease, must meet the following:
    • Member received prior therapy in the metastatic, neoadjuvant, or adjuvant setting and developed disease recurrence during or within 6 months of completing therapy; AND
    • Member has received ≥ 1 prior anti-HER2-based regimens; OR
  • For HER-2 low [immunohistochemistry (IHC) 1+ or IHC 2+/in situ hybridization (ISH)-] disease, must meet the following:
    • Member received prior chemotherapy in the metastatic setting or developed disease recurrence during or within 6 months of completing adjuvant chemotherapy.

Enhertu^® (Fam-Trastuzumab Deruxtecan-nxki) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• Unresectable or metastatic NSCLC; AND
• Disease is human epidermal growth factor receptor 2 (HER2)-positive; AND
• Member must have received a prior systemic therapy.

Enhertu^® (Fam-Trastuzumab Deruxtecan-nxki) Approval Criteria [Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma Diagnosis]:

• Diagnosis of locally advanced or metastatic gastric or GEJ adenocarcinoma; and
• Human epidermal growth factor receptor 2 (HER2)-positive disease; and
• Member has received at least 1 prior trastuzumab-based regimen.

Erivedge® (Vismodegib) Approval Criteria [Basal Cell Carcinoma Diagnosis]: 

• Either of the following criteria must be met for approval: 
  • Diagnosis of locally advanced basal cell carcinoma (BCC) that has either: 
    • Recurred following surgery or radiation therapy; OR
    • Surgery or radiation is contraindicated; OR
  • Diagnosis of metastatic basal cell carcinoma. 

Prior Authorization Form - Erivedge

apalutamide (Erleada™) Interim Approval Criteria:  

• A diagnosis of nonmetastatic prostate cancer; AND
• Castration-resistant or disease progression while on androgen deprivation therapy; AND
• Prostate specific antigen doubling time of ≤ 10 months; AND
• Concomitant treatment with a gonadotropin-releasing hormone (GnRH) analog or prior history of bilateral orchiectomy.

Prior Authorization Form

Erwinase^® (Crisantaspase), Erwinaze^® (Asparaginase Erwinia Chrysanthemi), and Rylaze™ [Asparaginase Erwinia Chrysanthemi (Recombinant)-rywn] Approval Criteria [Acute Lymphoblastic Leukemia (ALL) or Lymphoblastic Lymphoma Diagnosis]:

• Diagnosis of ALL or lymphoblastic lymphoma; and
• Used as a component of multi-agent chemotherapy; and
• Member has a documented hypersensitivity to Escherichia coli-derived asparaginase.

Erwinaze®/Rylaze™ PA Form

Exkivity^® (Mobocertinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• Diagnosis of advanced or metastatic NSCLC; and
• Tumor exhibits epidermal growth factor receptor (EGFR) exon 20 insertion mutations; and
• Disease has progressed on or after platinum-based chemotherapy; and
• As a single agent.

Exkivity® PA Form

Farydak^® (Panobinostat) Approval Criteria [Multiple Myeloma Diagnosis]:

• Diagnosis of relapsed or refractory multiple myeloma (RRMM); and
• Used in combination with bortezomib and dexamethasone after 1 or more lines of therapy; or
• Used in combination with carfilzomib or dexamethasone and lenalidomide after 2 or more lines of therapy (including bortezomib and an immunomodulatory agent).

Fotivda^® (Tivozanib) Approval Criteria [Renal Cell Carcinoma (RCC) Diagnosis]:

• 1.     Diagnosis of relapsed or refractory advanced RCC; and
• 2.     Member has received at least 2 prior systemic therapies; and
• 3.     As a single-agent.

Gavreto™ (Pralsetinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]: 

• Diagnosis of NSCLC in adults; and
• Recurrent, advanced, or metastatic disease; and
• Rearranged during transfection (RET) fusion-positive tumor. 

• Adult and pediatric members 12 years of age and older; and
• Diagnosis of advanced or metastatic disease with either:
  • Rearranged during transfection (RET)-mutant medullary thyroid cancer (MTC) requiring systemic therapy; or
  • RET fusion-positive thyroid cancer requiring systemic therapy and member is radioactive iodine-refractory (if radioactive iodine is appropriate). 

Gazyva® (Obinutuzumab) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:  

• As a single-agent for relapsed or refractory disease; OR
• In combination with chlorambucil, bendamustine, ibrutinib, or venetoclax for first-line therapy; AND
• When obinutuzumab is used in combination with venetoclax, maximum approval duration will be 6 treatment cycles of obinutuzumab.

Gazyva® (Obinutuzumab) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]:

• Grade 1 or 2 patients with Stage I (≥7cm), contiguous Stage II (≥7cm), noncontiguous Stage II, Stage III, or Stage IV patients (first, second, or subsequent therapy); AND
• In combination with CHOP (cyclophosphamide, doxorubicin, vincristine, AND prednisone), CVP (cyclophosphamide, vincristine, and prednisone), or bendamustine; AND
• When used for maintenance therapy a total of 12 doses will be approved.

Gazyva® (Obinutuzumab) Approval Criteria [Gastric or Nongastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma, Nodal or Splenic Marginal Zone Lymphoma (MZL) Diagnosis]:

• As second-line or subsequent therapy in combination with bendamustine; OR
• Maintenance therapy as second-line consolidation or extended dosing in rituximab-refractory patients treated with obinutuzumab and bendamustine for a total of 12 doses.

Prior Authorization Form - Gazyva

Gilotrif® (Afatinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

The following criteria must be met when used in the first-line setting: 

• A diagnosis of metastatic NSCLC; AND
• Epidermal growth factor receptor (EGFR) mutation detected; AND
• Afatinib when used in the first-line setting must be used as a single-agent only. 

The following criteria must be met when used in the second-line setting: 

• A diagnosis of metastatic NSCLC; AND
• Progressed following platinum-based chemotherapy; AND
• Afatinib when used in the second-line setting may be used as a single-agent or in combination with cetuximab in patients with a known sensitizing EGFR mutation who are T790M negative.

Gilotrif® (Afatinib) Approval Criteria [Head and Neck Cancer Diagnosis]:

• A diagnosis of head and neck cancer; AND
• Disease progression on or after platinum containing chemotherapy; AND
• Non-nasopharyngeal cancer must be one of the following:  
  • Newly diagnosed T4b, any N, M0 disease, unresectable nodal disease with no metastases, or for patients who are unfit for surgery and performance status (PS) 3; OR
  • Metastatic (M1) disease at initial presentation, recurrent/persistent disease with distant metastases, or unresectable locoregional recurrence or second primary with prior radiation therapy (RT) and PS 0 to 2; OR
  • Unresectable locoregional recurrence without prior RT and PS 3; AND
• Afatinib must be used as a single-agent. 

Prior Authorization Form - Gilotrif

Halaven® (Eribulin) Approval Criteria (Medical Billing Only):   

• Diagnosis of metastatic breast cancer; AND 
• Previously received at least two chemotherapeutic regimens for the treatment of metastatic disease. Prior therapy should have included an anthracycline and a taxane in either the adjuvant or metastatic setting.

Halaven® (Eribulin) Approval Criteria [Liposarcoma Diagnosis]:

• Diagnosis of unresectable or metastatic liposarcoma; AND         
• Previously received an anthracycline-containing chemotherapy regimen.
• Authorizations will be for the duration of three months. Reauthorization may be granted if the patient does not show evidence of progressive disease while on eribulin therapy. 

Prior Authorization Form - Halaven

Hemady™ (Dexamethasone 20mg Tablet) Approval Criteria [Multiple Myeloma Diagnosis]:

• Diagnosis of multiple myeloma; and
• A patient-specific, clinically significant reason (beyond convenience) why the member cannot use dexamethasone 4mg tablets to achieve the required dose in place of Hemady™ must be provided.

Herceptin^® (Trastuzumab), Herceptin Hylecta™ (Trastuzumab/Hyaluronidase-oysk), Herzuma^® (Trastuzumab-pkrb), Kanjinti^® (Trastuzumab-anns), Ogivri^® (Trastuzumab-dkst), Ontruzant^® (Trastuzumab-dttb), and Trazimera™ (Trastuzumab-qyyp) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of human epidermal receptor 2 (HER2)-overexpressing breast cancer; AND
• Authorization of Herceptin^® (trastuzumab), Herceptin Hylecta™ (trastuzumab/ hyaluronidase-oysk), Herzuma^® (trastuzumab-pkrb), Kanjinti^® (trastuzumab-anns), or Ogivri^® (trastuzumab-dkst) will also require a patient-specific, clinically significant reason why the member cannot use Ontruzant^® (trastuzumab-dttb), or Trazimera™ (trastuzumab-qyyp). Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products.  

Herceptin^® (Trastuzumab), Herzuma^® (Trastuzumab-pkrb), Kanjinti^® (Trastuzumab-anns), Ogivri^® (Trastuzumab-dkst), Ontruzant^® (Trastuzumab-dttb), and Trazimera^® (Trastuzumab-qyyp) Approval Criteria [Colorectal Cancer (CRC) Diagnosis]:

• Diagnosis of human epidermal receptor type 2 (HER2)-positive CRC; AND
• RAS and BRAF mutation negative; AND
• Used in combination with pertuzumab or lapatinib; AND
• Used in 1 of the following settings:
  • If first-line therapy, member should not be a candidate for intensive therapy; OR
  • For the treatment of advanced or metastatic disease following disease progression; AND
• Authorization of Herceptin^® (trastuzumab), Herzuma^® (trastuzumab-pkrb), Kanjinti^® (trastuzumab-anns), or Ogivri^® (trastuzumab-dkst) will also require a patient-specific, clinically significant reason why the member cannot use Ontruzant^® (trastuzumab-dttb) or Trazimera^® (trastuzumab-qyyp). Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products. 

Herceptin^® (Trastuzumab), Herzuma^® (Trastuzumab-pkrb), Kanjinti^® (Trastuzumab-anns), Ogivri^® (Trastuzumab-dkst), Ontruzant^® (Trastuzumab-dttb), and Trazimera™ (Trastuzumab-qyyp) Approval Criteria [Metastatic Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma Diagnosis]:

• Diagnosis of human epidermal receptor 2 (HER2)-overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma; AND
• Authorization of Herceptin^® (trastuzumab), Herzuma^® (trastuzumab-pkrb), Kanjinti^® (trastuzumab-anns), or Ogivri® (trastuzumab-dkst) will also require a patient-specific, clinically significant reason why the member cannot use Ontruzant^® (trastuzumab-dttb), or Trazimera™ (trastuzumab-qyyp). Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products.

Prior Authorization Form

Ibrance® (palbociclib)* Approval Criteria [Breast Cancer Diagnosis]: (Pharmacy Billing Only):  

• A diagnosis of advanced metastatic, hormone receptor positive, Human Epidermal Receptor Type 2 (HER2)-negative breast cancer in combination with:
  • An aromatase inhibitor in postmenopausal women; or 
  • Fulvestrant in women with disease progression following endocrine therapy. 
  • An aromatase inhibitor or fulvestrant in male patients.

Prior Authorization

Iclusig® (Ponatinib) Approval Criteria [Philadelphia Chromosome Positive (Ph+) Acute Lymphoblastic Leukemia (ALL) Diagnosis]:

• Member must have 1 of the following:
  • Induction/consolidation with hyperfractionated cyclophosphamide, vincristine sulfate, doxorubicin hydrochloride (Adriamycin^®), and dexamethasone (HyperCVAD); or
  • Maintenance therapy in combination with vincristine and prednisone, with or without methotrexate and mercaptopurine; or
  • Maintenance therapy post-hematopoietic stem cell transplantation; or
  • Relapsed/refractory disease either as a single agent, in combination with chemotherapy not previously given, or in patients with T315I mutations.       

Iclusig^® (Ponatinib) Approval Criteria [Chronic Myeloid Leukemia (CML) Diagnosis]: 

• Member must have 1 of the following:
  • T315I mutation; or
  • intolerant or resistant to 2 or more tyrosin kinase inhibitors (TKIs); or
  • Post-hemotopoietic stem cell transplantation in members with prior accelerated or blast phase prior to transplant or who have relapsed.

Idhifa® (Enasidenib) Approval Criteria [Acute Myeloid Leukemia (AML) Diagnosis]:  

• Newly diagnosed AML in members 75 years of age or older or in adult members who have comorbidities that preclude use of intensive chemotherapy; AND
  • As a single-agent; AND
  • IDH2 mutation; OR 
• Relapsed/refractory AML; AND
  • As a single-agent; AND
  • IDH2 mutation. 

Prior Authorization Form - Idhifa

Imbruvica® (Ibrutinib) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]: 

• A diagnosis of Grade 1 or 2 FL; AND
• As subsequent therapy (third-line or greater) for histologic transformation to non-germinal center diffuse large B-cell lymphoma.

Imbruvica® (Ibrutinib) Approval Criteria [Gastric or Nongastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma, Nodal or Splenic Marginal Zone Lymphoma (MZL) Diagnosis]:

• As second-line or subsequent therapy for refractory or progressive disease.

Imbruvica® (Ibrutinib) Approval Criteria [Chronic Graft-Versus-Host Disease (cGVHD) Diagnosis]:

• A diagnosis of cGVHD after failure of one or more lines of therapy.

Imbruvica® (Ibrutinib) Approval Criteria [Histologic Transformation of Marginal Zone Lymphoma (MZL) to Diffuse Large B-Cell Lymphoma Diagnosis]:

• As third-line or greater therapy for patients who have transformed to non-germinal center diffuse large B-cell lymphoma.

Imbruvica® (Ibrutinib) Approval Criteria [Mantle Cell Lymphoma (MCL) Diagnosis]:

• As second-line or subsequent therapy; AND
• Used as a single-agent or in combination with rituximab or lenalidomide/rituximab.

Imbruvica® (Ibrutinib) Approval Criteria [Diffuse Large B-Cell Lymphoma Diagnosis or Acquired Immunodeficiency Syndrome (AIDS)-Related B-Cell Lymphoma Diagnosis]:

• A diagnosis of non-germinal center diffuse large B-cell lymphoma; AND      
• As second-line or subsequent therapy; AND
• Member is not a candidate for high-dose therapy.

Imbruvica® (Ibrutinib) Approval Criteria [Post-Transplant Lymphoproliferative Disorders Diagnosis]:

• As second-line and subsequent therapy in patients with partial response, persistent, or progressive disease; AND
• Non-germinal center B-cell type.

Imbruvica® (Ibrutinib) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:

• As first or subsequent therapy for CLL/SLL; AND
• As a single-agent or in combination with bendamustine/rituximab, rituximab, or obinutuzumab.

Imbruvica® (Ibrutinib) Approval Criteria [Hairy Cell Leukemia Diagnosis]:

• As a single-agent in patients with indication for treatment for progression.

Imbruvica® (Ibrutinib) Approval Criteria [Waldenström’s Macroglobulinemia (WM)/Lymphoplasmacytic Lymphoma Diagnosis]:

• As first or subsequent therapy; AND
• As a single-agent or in combination with rituximab.

Prior Authorization - Imbruvica

Imfinzi® (Durvalumab) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• A diagnosis of unresectable stage II or III NSCLC; AND
• Disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy.

• Diagnosis of ES-SCLC; and
• In combination with etoposide and either cisplatin or carboplatin followed by single-agent maintenance.

Prior Authorization Form  

Imlygic® (Talimogene Laherparepvec) Approval Criteria [Melanoma Diagnosis]:  

All of the following criteria must be met for approval:

• Patient has unresectable cutaneous, subcutaneous, or nodal lesions that are recurrent after initial surgery; AND
• Talimogene laherparepvec is not indicated with visceral metastases.
• The patient is not immunocompromised or pregnant.

Prior Authorization Form - Imlygic

Inrebic® (fedratinib) Approval Criteria [Myelofibrosis Diagnosis]:  

• Diagnosis of myelofibrosis in adult members;AND
• Intermediate-2 or high-risk primary or secondary (post-polycythemia vera or post-essential thrombocythemia).

Prior Authorization Form - Inrebic

Inqovi^® (Decitabine/Cedazuridine) Approval Criteria [Myelodysplastic Syndromes (MDS) Diagnosis]: 

• A diagnosis of MDS (intermediate-1, intermediate-2, or high risk) in adults including previously treated and untreated, de novo, and secondary MDS with the following subtypes:
  • Refractory anemia; or
  • Refractory anemia with ring sideroblasts; or
  • Refractory anemia with excess blasts; or
  • Chronic myelomonocytic leukemia (CMML).

Istodax^® (Romidepsin) and Romidepsin 27.5mg/5.5mL Vial Approval Criteria [Primary Cutaneous Lymphomas – Mycosis Fungoides (MF)/Sézary Syndrome (SS) Diagnosis]: 

• As a single-agent as primary treatment or in relapsed/refractory disease. 

• As a single-agent in members with multifocal lesions or regional nodes either as primary treatment or in relapsed/refractory disease. 

• As a single-agent in relapsed/refractory disease. 

• As a single-agent; and
• Relapsed/refractory disease following additional therapy with an alternate combination chemotherapy regimen not previously used. 

Ixempra® (Ixabepilone) Approval Criteria [Breast Cancer Diagnosis]:  

• Diagnosis of metastatic or locally advanced breast cancer; AND 
• Used in combination with capecitabine; AND
  • After failure of an anthracycline and a taxane unless anthracycline contraindicated; OR
• Used as a single agent; AND
  • Used in 1 of the following settings:
    • After failure of capecitabine, an anthracycline, and a taxane; OR
    • In members with no response to preoperative systemic therapy; OR
    • After at least 1 line of therapy for recurrent unresectable (local or regional) disease; OR
    • Disease is human epidermal growth factor receptor 2 (HER2)-negative; OR
• Used in combination with trastuzumab; and
  • Disease is HER2-positive; AND
  • Third-line or subsequent therapy.

 Prior Authorization Form - Ixempra   

Jakafi^® (Ruxolitinib) Approval Criteria [Graft-Versus-Host Disease (GVHD) Diagnosis]:

• Diagnosis of acute or chronic GVHD; and
• Failure of at least 1 prior line of systemic therapy; and
• Member must be 12 years of age or older.

Jakafi^® (Ruxolitinib) Approval Criteria [Myelofibrosis (MF) Diagnosis]:

• Diagnosis of MF; and
• Used in 1 of the following settings:   
  • Symptomatic lower-risk MF with no response or loss of response to peginterferon alfa-2a or hydroxyurea; or
  • Intermediate to high-risk MF; and           
• Member must be 18 years of age or older.

Jakafi^® (Ruxolitinib) Approval Criteria [Polycythemia Vera Diagnosis]:

• Diagnosis of polycythemia vera; and
• Inadequate response or loss of response to hydroxyurea or peginterferon alfa-2a therapy; and
• Member must be 18 years of age or older. 

Jelmyto^® (Mitomycin) Approval Criteria [Urothelial Cancer Diagnosis]:

• 1.     Diagnosis of non-metastatic upper urinary tract tumor; and
• 2.     Must be a single, residual, low-grade, low-volume (5 to 15mm) tumor; and
• 3.     Member is not a candidate for nephroureterectomy; and
• 4.    Initial approvals will be for the duration of 6 weeks. With documentation from the prescriber of complete response 3 months after initial treatment, subsequent approvals may be authorized for once monthly use for up to 11 additional instillations.  

Jemperli^® (Dostarlimab-gxly) Approval Criteria [Endometrial Cancer Diagnosis]:

• Diagnosis of advanced, recurrent, or metastatic endometrial cancer; and
• Mismatch repair deficient (dMMR) disease; and
• Disease has progressed on or following prior treatment with a platinum-containing regimen.

Jemperli^® (Dostarlimab-gxly) Approval Criteria [Mismatch Repair Deficient (dMMR) Solid Tumor Diagnosis]:

• Diagnosis of recurrent or advanced solid tumors that are mismatch repair deficient (dMMR); and
• Disease has progressed on or following prior treatment; and
• There are no satisfactory treatment alternatives for the member.

Jemperli® PA Form

Jevtana® (Cabazitaxel) Approval Criteria (Medical Billing Only): 

• A diagnosis of metastatic, castration-resistant prostate cancer; AND
• Member must have been previously treated with a docetaxel-containing regimen; AND
• Cabazitaxel should be used in combination with prednisone; AND
• Approvals will be for the duration of three months at which time additional authorization may be granted if the prescriber documents that the member has not shown evidence of progressive disease while on cabazitaxel therapy.

Prior Authorization Form - Jevtana  

Kadcyla® (Ado-Trastuzumab) Approval Criteria (Medical Billing Only):                  

• Positive expression of Human Epidermal Receptor Type 2 (HER2); AND
• Diagnosis of metastatic breast cancer; AND
• Member has previously received trastuzumab and a taxane, separately or in combination; AND
• Members should also have either:
  • Received prior therapy for metastatic disease; OR
  • Developed disease recurrence during or within six months of completing adjuvant therapy. 

Prior Authorization Form - Kadcyla

Keytruda^® (Pembrolizumab) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of locally recurrent unresectable or metastatic triple-negative breast cancer; AND
  • Tumors express programmed death ligand 1 (PD-L1) with a combined positive score (CPS) ≥10; AND
  • Used in combination with chemotherapy; OR  
• Diagnosis of early stage triple-negative breast cancer; AND
  • Disease is considered high-risk; AND
  • Used in combination with chemotherapy as neoadjuvant therapy.

Keytruda® (Pembrolizumab) Approval Criteria [Cervical Cancer Diagnosis]:   

• A diagnosis of recurrent or metastatic cervical cancer; AND
• Tumors must express PD-L1 [Combined Positive Score (CPS) ≥1]; AND  
• The patient has not previously failed other PD-1 inhibitors [e.g., Opdivo® (nivolumab)]; AND
  • Disease progression on or after chemotherapy; OR
  • As first-line therapy in combination with chemotherapy, with or without bevacizumab.

 Keytruda^® (Pembrolizumab) Approval Criteria [Colorectal Cancer (CRC) Diagnosis]:

• Diagnosis of unresectable or metastatic CRC; AND
• Tumor is microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR).

Keytruda® (Pembrolizumab) Approval Criteria [Endometrial Cancer Diagnosis]:  

• Member has not previously failed other PD-1 inhibitors [e.g., Opdivo (nivolumab)]; AND
• Disease progression following prior systemic therapy; AND
• Member is not a candidate for curative surgery or radiation; AND
• Used in 1 of the following settings:
  • In combination with lenvatinib for advanced endometrial cancer that is not microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR); OR
  • As a single agent for advanced endometrial cancer that is MSI-H or dMMR.

Keytruda® (Pembrolizumab) Approval Criteria [Esophageal, or Gastroesophageal Junction (GEJ) Cancer Diagnosis]:

• Diagnosis of locally advanced, recurrent, or metastatic esophageal, or GEJ carcinoma; AND
• Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Opdivo (nivolumab)].
• For first-line therapy:
  • Must be used in combination with platinum- and fluoropyrimidine- based chemotherapy; OR
• For second-line or greater therapy:
  • Must be used following disease progression after 1 or more prior lines of systemic therapy; AND
  • Tumor must be squamous cell histology; AND
  • Must be used as monotherapy; AND
  • Tumor expresses programmed death ligand 1 (PD-L1) [combined positive score (CPS ≥10).

Keytruda^® (Pembrolizumab) Approval Criteria [Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma Diagnosis]:

• Diagnosis of locally advanced, unresectable, or metastatic gastric or GEJ adenocarcinoma; AND
• Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Opdivo^® (nivolumab)]; AND
• For first-line therapy:
  • Human epidermal receptor 2 (HER2)-positive disease; AND
  • In combination with trastuzumab, fluoropyrimidine- and platinum-containing chemotherapy. 

Keytruda® (Pembrolizumab) Approval Criteria [ Classical Hodgkin Lymphoma (cHL) Diagnosis]:

• The member has not previously failed other programmed death 1 (PD-1) inhibitors [i.e. Opdivo^® (nivolumab)]; AND
• For adult members:
  • Diagnosis of relapsed or refractory cHL; AND
    • As a single agent; OR
    • Exception: Lymphocyte-predominant Hodgkin lymphoma; OR
    • Second-line or subsequent systemic therapy in combination with gemcitabine, vinorelbine, and liposomal doxorubicin; OR
• For pediatric members:
  • As a single agent; AND
  • Diagnosis of refractory cHL; OR
  • Relapsed disease after ≥2 therapies.

Keytruda® (Pembrolizumab) Approval Criteria [Metastatic Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• All of the following criteria must be met for approval:
• Diagnosis of metastatic NSCLC; AND
• The patient has not previously failed other PD-1 inhibitors [i.e. Opdivo® (nivolumab)]; AND
• Tumor proportion scores for PD-L1 expression as follows:
  • Single-agent, first-line: ≥1% 
  • First-line in combination with carboplatin and pemetrexed: no expression required 
  • Second-line: ≥1%; AND  
• Patient meets one of the following:
  • Previously untreated metastatic non-squamous non-small cell lung cancer (NSCLC) in combination with pemetrexed and carboplatin; OR
  • New diagnosis as first-line therapy (patient has not received chemotherapy to treat disease) if:
    • Tumor does not express sensitizing EGFR mutations or ALK translocations; OR
  • Single-agent for disease progression on or after platinum-containing chemotherapy (cisplatin or carboplatin): 
    • Patients with EGFR-mutation-positive should have disease progression on FDA-approved therapy for these aberrations prior to receiving pembrolizumab. This does not apply if tumors do not have these mutations; AND
      • Examples of drugs for EGFR-mutation-positive tumors: osimertinib, eroltinib, afatinib, or gefitinib  
    • Patients with ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving pembrolizumab.  This does not apply if tumors do not have these mutations; AND
      • Examples of drugs for ALK-mutation-positive tumors: crizotinib, ceritinib, or alectinib  

Keytruda® (Pembrolizumab) Approval Criteria [Head and Neck Cancer Diagnosis]: 

• All of the following criteria must be met for approval:
  • Squamous cell histology; AND
  • If used in the recurrent setting, member has not previously failed other PD-1 inhibitors [[e.g., Opdivo® (nivolumab)]; AND
  • Dose does not exceed 200mg every three weeks. 

Keytruda® (Pembrolizumab) Approval Criteria [Melanoma Diagnosis]:

• All of the following criteria must be met for approval:
  • Diagnosis of unresectable or metastatic melanoma; AND   
  • Pembrolizumab must be used as a single-agent; AND
  • Patient meets one of the following:
    • Pembrolizumab is being used as first-line therapy; OR
    • Pembrolizumab is being used as second-line therapy or subsequent therapy for disease progression if not previously used; AND
  • The patient has not previously failed other PD-1 inhibitors [i.e. Opdivo® (nivolumab)].  

Keytruda® (Pembrolizumab) Approval Criteria [Microsatellite Instability-High (MSI-H) or Mismatch Repair Deficient (dMMR) Solid Tumor (Tissue/Site-Agnostic) Diagnosis]:

• Member has not previously failed other programmed death 1 (PD-1) inhibitors [i.e., Opdivo^® (nivolumab)]; AND
• MSI-H or dMMR solid tumors that have progressed following prior treatment with no satisfactory alternative treatment options.

Keytruda® (Pembrolizumab) Approval Criteria [Non-Muscle Invasive Bladder Cancer (NMIBC) Diagnosis]:

• A diagnosis of high-risk, NMIBC; AND
• Member must have failed therapy with Bacillus Calmette-Guerin (BCG)-therapy; AND
• Member must be ineligible for or has elected not to undergo cystectomy. 

Keytruda® (Pembrolizumab) Approval Criteria [Primary Mediastinal Large B-cell Lymphoma (PMBCL) Diagnosis]:

• A diagnosis of PMBCL in adult or pediatric patients; AND
• Patient must have refractory disease or pembrolizumab must be used in patients who have relapsed after 2 or more prior lines of therapy; AND
• Authorizations will not be granted for patients who require urgent cytoreduction; AND
• The patient has not previously failed other PD-1 inhibitors [e.g., Opdivo® (nivolumab)].
  
  

Keytruda® (Pembrolizumab) Approval Criteria [Urothelial Carcinoma Diagnosis]:

• Locally advanced or metastatic urothelial carcinoma who have disease progression during or following platinum-containing chemotherapy; OR  
• Within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy; OR  
• Frontline pembrolizumab for patients with locally advanced or metastatic urothelial carcinoma who are not eligible for cisplatin-containing chemotherapy.
  • Cisplatin ineligibility is defined as:
    • Baseline creatinine clearance of <60mL/min, or Class III heart failure, or grade 2 or greater peripheral neuropathy, or grade 2 or greater hearing loss.  

Keytruda® (Pembrolizumab) Approval Criteria [Gastric or Gastroesophageal Junction Tumor Diagnosis]:

• Recurrent, locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma; AND
• Tumors must express PD-L1; AND
• Disease progression on or after 2 or more prior systemic therapies (including fluoropyrimidine- and platinum-containing chemotherapy, and if appropriate, HER2/neu-targeted therapy).

Keytruda® (Pembrolizumab) Approval Criteria [Nonmetastatic Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:  

• A diagnosis of stage 3 NSCLC; AND  
• Ineligible for surgery or definitive chemoradiation; AND
• Tumor proportion scores for PD-L1 expression ≥1%; AND
• The member has not previously failed other PD-1 inhibitors [e.g., Opdivo® (nivolumab)]. 

Keytruda® (Pembrolizumab) Approval Criteria [Non-Muscle Invasive Bladder Cancer (NMIBC) Diagnosis]:

• A diagnosis of high-risk, NMIBC; AND
• Member must have failed therapy with Bacillus Calmette-Guerin (BCG)-therapy; AND
• Member must be ineligible for or has elected not to undergo cystectomy. 

Keytruda® (Pembrolizumab) Approval Criteria [Renal Cell Carcinoma (RCC) Diagnosis]:  

• Member must have newly diagnosed or recurrent stage 4 clear-cell RCC; AND
  • Have received no previous systemic therapy for advanced disease; AND
  • Must be used in combination with Inlyta® (axitinib) or lenvatinib; ; AND
  • The member has not previously failed other PD-1 inhibitors [e.g., Opdivo® (nivolumab)].; OR
• Diagnosis of RCC at intermediate-high or high risk of recurrence following nephrectomy, or following nephrectomy and resection of metastatic lesions.

Keytruda^® (Pembrolizumab) Approval Criteria [Tumor Mutational Burden-High (TMB-H) Solid Tumors Diagnosis]:

• Diagnosis of unresectable or metastatic TMB-H [≥10 mutations/megabase (mut/Mb)] solid tumors; AND
• Used following disease progression after prior treatment; AND 
• No satisfactory alternative treatment options.

Keytruda® (Pembrolizumab) Approval Criteria [Small Cell Lung Cancer (SCLC) Diagnosis]:

• Diagnosis of metastatic SCLC; AND
• Progressed on or following a platinum-based regimen and at least 1 other regimen; AND
• Member has not previously failed other PD-1 inhibitors [e.g., Opdivo® (nivolumab)].

Prior Authorization Form - Keytruda

Kisqali® (Ribociclib) Approval Criteria [Breast Cancer Diagnosis]: 

• Member must be Hormone Receptor (HR)-positive; AND
• Member must be Human Epidermal Receptor Type 2 (HER2)-negative; AND
• If used in combination with an aromatase inhibitor: 
  • Diagnosis of advanced or metastatic breast cancer, initial therapy; OR 
• If used in combination with fulvestrant: 
  • Diagnosis of advanced or metastatic breast cancer, as initial endocrine based therapy or following disease progression on endocrine therapy; AND
  • Must be used in postmenopausal women only.  

Kisqali® Femara® Co-Pack (Ribociclib/Letrozole) Approval Criteria:

• A diagnosis of advanced or metastatic breast cancer, initial therapy; AND
• Member must be Hormone Receptor (HR)-positive; AND
• Member must be Human Epidermal Receptor Type 2 (HER2)-negative.

Prior Authorization Form - Kisqali

Koselugo™ (Selumetinib) Approval Criteria [Neurofibromatosis Type 1 (NF1) Diagnosis]:

Member meets all of the following:

• Pediatric patients 2 years of age and older; AND
• Diagnosis of NF1 with symptomatic, inoperable plexiform neurofibromas. 

tisagenlecleucel (Kymriah™) Approval Criteria [Lymphoma Diagnosis]:  

• Large B-cell lymphoma [including diffuse large B-cell lymphoma (DLBCL), high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma (FL)]; AND
• Relapsed or refractory disease; AND
• Member must be 18 years of age or older;  AND
• Member must not have primary central nervous system lymphoma; AND
• Member must have had two or more lines of therapy; AND
• Health care facilities must be on the certified list to administer chimeric antigen receptor (CAR) T-cells and must be trained in the management of cytokine release syndrome (CRS), neurologic toxicities, and comply with the REMS requirements.  

 tisagenlecleucel (Kymriah™) Approval Criteria [Acute Lymphoblastic Leukemia (ALL) Diagnosis]:

• All of the following must be met for approval:
  • B-Cell precursor acute lymphoblastic leukemia (ALL); AND
  • Member must be 25 years of age or younger; AND
  • Refractory or in second or later relapse:
    • Philadelphia chromosome negative (Ph-) ALL: must be refractory or with ≥2 relapses; OR
    • Philadelphia chromosome positive (Ph+) ALL: must have failed ≥2 Tyrosine Kinase Inhibitors (TKIs); AND
  • Therapies to consider prior to tisagenlecleucel if appropriate: clinical trial, multi-agent chemotherapy with or without hematopoietic cell transplantation (HCT), blinatumomab (category 1 recommendation), and inotuzumab (category 1 recommendation).  
• Healthcare facilities must be on the certified list to administer CAR T cells and must be trained in the management of cytokine release syndrome (CRS), neurologic toxicities, and comply with the REMS requirements.   

Prior Authorization

Lenvima^® (Lenvatinib) Approval Criteria [Differentiated Thyroid Cancer (DTC) Diagnosis]: 

• Locally recurrent or metastatic disease; and
• Disease progression on prior treatment; and
• Radioactive iodine-refractory disease.

• Advanced disease; and
• Used in combination with pembrolizumab; or
• Following 1 prior anti-angiogenic therapy; and
• Used in combination with everolimus.

• Unresectable disease; and
• First-line treatment.

• Advanced disease with progression on prior systemic therapy; and
• Member is not a candidate for curative surgery or radiation; and
• Disease is not microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR); and
• Used in combination with pembrolizumab.

Lenvima - PA

Libtayo® (Cemiplimab-rwlc) Approval Criteria [Cutaneous Squamous Cell Carcinoma (CSCC) Diagnosis]:   

• Diagnosis of metastatic or locally advanced CSCC; AND
• Member is not eligible for curative surgery or radiation; AND
• Member has not received prior immunotherapy agent(s) [e.g., Keytruda® (pembrolizumab), Opdivo® (nivolumab), Yervoy® (ipilimumab)].  

• Diagnosis of locally advanced or metastatic BCC; and
• Member has previously been treated with a hedgehog pathway inhibitor (HHI); or
• Treatment with a HHI is not appropriate for the member.

• Diagnosis of advanced, unresectable, or metastatic NSCLC; and
• High programmed death ligand 1 (PD-L1) expression [tumor proportion score (TPS) ≥50%]; and
• No epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), or ROS1 mutations.

Prior Authorization Form - Libtayo

Lonsurf^® (Trifluridine/Tipiracil) Approval Criteria [Colorectal Cancer (CRC) Diagnosis]:

• Diagnosis of metastatic, recurrent, or unresectable CRC; AND
• Previously treated with a fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy; AND
• Previously treated with an anti-vascular endothelial growth factor (VEGF) therapy; AND
• If RAS wild-type disease, previously treated with an anti-epidermal growth factor receptor (EGFR) therapy; AND
• Used as monotherapy or in combination with bevacizumab.

Lonsurf^® (Trifluridine/Tipiracil) Approval Criteria [Gastric or Gastroesophageal Junction (GEJ) Adenocarcinoma Diagnosis]:

• Diagnosis of metastatic gastric or GEJ adenocarcinoma; AND
• Previously treated with at least 2 prior lines of chemotherapy that included a fluoropyrimidine, a platinum, paclitaxel, docetaxel, or irinotecan; AND
• If human epidermal receptor type 2 (HER2) positive disease, prior treatment should have included HER2 targeted therapy.

Lorbrena® (Lorlatinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:   

• A diagnosis of metastatic NSCLC; AND  
• Tumor expresses anaplastic lymphoma kinase (ALK) translocation; AND
• As a single-agent as first-line therapy; OR
• Used as a single-agent as second-line therapy following disease progression on either alectinib or ceritinib; OR  
• Used as a single-agent as third-line or greater therapy following disease progression on crizotinib and 1 other ALK inhibitor (i.e., ceritinib, alectinib). 

Prior Authorization Form - Lorbrena 

Lumakras™ (Sotorasib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• Diagnosis of locally advanced or metastatic NSCLC; and
• Presence of KRAS G12C mutation; and
• Disease has progressed on at least 1 prior systemic therapy; and
• As a single agent.

Lumakras™ PA Form

Lumoxiti® (Moxetumomab Pasudotox-tdfk) Approval Criteria [Hairy Cell Leukemia (HCL) Diagnosis]:

• Treatment of relapsed or refractory HCL in adults; AND
• Member has received at least 2 prior systemic therapies, including treatment with a purine nucleoside analog (PNA); AND
• Creatinine clearance (CrCl) ≥30mL/minute/1.73m2; AND
• As a single-agent. 

Prior Authorization Form - Lumoxiti

Lutathera® (Lutetium Lu 177 Dotatate) Approval Criteria [Gastroenteropancreatic Neuroendocrine Tumor (GEP-NET) Diagnosis]:  

• Diagnosis of progressive locoregional advanced disease or metastatic disease; AND
• Positive imaging of somatostatin receptor; AND  
• Must be used as second-line or subsequent therapy following progression on octreotide or lanreotide; OR  
• May be used first-line for treatment of pheochromocytoma/paraganglioma.  

Prior Authorization Form

Lynparza^® (Olaparib) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of human epidermal growth factor receptor 2 (HER2)-negative, high-risk early breast cancer previously treated with neoadjuvant or adjuvant chemotherapy; AND
  • Used in the adjuvant setting; and
  • Positive test for a germline BRCA-mutation (gBRCAm); AND
  • Maximum treatment duration of 1 year; OR
• Diagnosis of metastatic breast cancer; AND
  • Member must have shown progression on previous chemotherapy; AND
  • Positive test for a germline BRCA-mutation (gBRCAm); AND
  • Members with hormone receptor (HR) positive disease must have failed prior endocrine therapy or are not considered to be a candidate for endocrine therapy. 

Lynparza® (Olaparib) Approval Criteria [Ovarian, Fallopian Tube, or Primary Peritoneal Cancer Diagnosis]:   

• Treatment of Advanced Recurrent/Refractory Disease:
  • Diagnosis of deleterious or suspected deleterious germline BRCA-mutated (gBRCAm), advanced disease; and
  • Previous treatment with ≥2 prior lines of chemotherapy (prior chemotherapy regimens should be documented on the prior authorization request); and
  • A quantity limit based on FDA approved dosing will apply; or 
• Maintenance Treatment of Advanced Disease: 
  • Disease must be in a complete or partial response to primary chemotherapy; and 
    • Used as a single-agent in members with a diagnosis of deleterious or suspected deleterious gBRCAm or somatic BRCA-mutated (sBRCAm), advanced ovarian cancer; or
    • Used in combination with bevacizumab following a primary therapy regimen that included bevacizumab; or
  • Complete or partial response to second-line or greater platinum-based based chemotherapy (no mutation required); and
  • A quantity limit based on FDA approved dosing will apply.

Lynparza® (Olaparib) Approval Criteria [Pancreatic Cancer Diagnosis]: 

• Diagnosis of metastatic pancreatic adenocarcinoma with known germline BRCA1/BRCA2 mutation; AND 
• Maintenance therapy as a single-agent; a AND 
• In members who have not progressed on at least 16 weeks of a first-line platinum-based chemotherapy regimen.

Lynparza® (Olaparib) Approval Criteria [Castration-Resistant Prostate Cancer (CRPC) Diagnosis]:

• Diagnosis of metastatic CRPC; AND
• Members must have failed previous first-line therapy; AND
• Used as a single-agent except for the following:
  • Concomitant treatment with a gonadotropin-releasing hormone (GnRH) analog or prior history of bilateral orchiectomy; AND
• Disease must be positive for a mutation in a homologous recombination gene.

Prior Authorization Form - Lynparza

Margenza^® (Margetuximab-cmkb) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of metastatic breast cancer; and
• Human epidermal growth factor receptor 2 (HER2)-positive; and
• Member has received 2 or more prior anti-HER2 regimens, at least 1 of which was for metastatic disease; and
• Used in combination with chemotherapy (capecitabine, eribulin, gemcitabine, or vinorelbine).

Prior Authorization

Mekinist® (Trametinib) Approval Criteria [Anaplastic Thyroid Cancer (ATC) Diagnosis]:

• Diagnosis of ATC; AND
• Locally advanced or metastatic disease; AND
• BRAF V600E mutation; AND
• No satisfactory locoregional treatment options.

Mekinist® (Trametinib) Approval Criteria [Melanoma Diagnosis]:  

• All of the following criteria must be met for approval:
  • Diagnosis of unresectable or metastatic melanoma; AND
  • BRAF V600E or V600K mutation detected by an FDA-approved test; AND
    • Trametinib is not indicated for wild-type BRAF melanoma. 
  • One of the following is met:
    • Used as first-line therapy in combination with dabrafenib; OR
    • Used as second-line therapy or subsequent therapy with dabrafenib and patient has an ECOG performance status of 0 to 2; OR
    • Used as second-line therapy or subsequent therapy as a single-agent if:
      • Patient was intolerant to prior BRAF inhibitor therapy (dabrafenib, vemurafenib); AND
      • No evidence of disease progression on prior BRAF inhibitor therapy (dabrafenib, vemurafenib) 

Mekinist® (Trametinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• All of the following criteria must be met for approval:
  • BRAF V600E or V600K mutation detected by an FDA-approved test; AND
    • Trametinib is not indicated for wild-type BRAF NSCLC 
  • Trametinib must be used in combination with dabrafenib. 
  • Diagnosis of refractory or metastatic disease. 

Mekinist^® (Trametinib) Approval Criteria [Serous Ovarian Cancer Diagnosis]:

• Diagnosis of persistent disease or recurrent low-grade serous carcinoma; and
• Meets 1 of the following:
  • Immediate treatment for serially rising CA-125 in members who previously received chemotherapy; or
  • Progression on primary, maintenance, or recurrence therapy; or
  • Stable or persistent disease (if not on maintenance therapy); or
  • Complete remission and relapse after receiving prior chemotherapy.

Prior Authorization Form - Mekinist

Mektovi® (Binimetinib) Approval Criteria [Melanoma Diagnosis]:

• Diagnosis of unresectable or metastatic melanoma; AND
• BRAF V600E or V600K mutation; AND
• Used in combination with encorafenib.

Prior Authorization Form - Mektovi

Monjuvi^® (Tafasitamab-cxix) Approval Criteria [Diffuse Large B-Cell Lymphoma (DLBCL) Diagnosis]: 

• Diagnosis of DLBCL in adults; and
• Relapsed or refractory disease; and
• Used in combination with lenalidomide.

Nerlynx™ (Neratinib) Approval Criteria:

• For adjuvant treatment in early stage breast cancer; AND
• Member must have Human Epidermal Receptor Type 2 (HER2)-overexpressed breast cancer; AND
• Neratinib must be used to follow adjuvant trastuzumab-based therapy. 
• Authorizations will be for the duration of three months. Reauthorization may be granted if the patient does not show evidence of progressive disease while on neratinib therapy. 

Nerlynx® (Neratinib) Approval Criteria [Recurrent or Metastatic Breast Cancer Diagnosis]:

• Diagnosis of recurrent or metastatic breast cancer; AND
• Member must have human epidermal growth factor receptor 2 (HER2)-positive breast cancer; AND
• Used in combination with capecitabine; OR
• Used in combination with capecitabine or paclitaxel if brain metastases are present.

Prior Authorization Form - Nerlynx

Ninlaro^® (Ixazomib) Approval Criteria [Multiple Myeloma Diagnosis]:

• Diagnosis of symptomatic multiple myeloma; and
• Used in 1 of the following settings:
  • As primary therapy; or
  •  Following disease relapse after 6 months following primary induction therapy with the same regimen, used in combination with 1 of the following regimens:
    • Lenalidomide and dexamethasone; or
    • Cyclophosphamide and dexamethasone for transplant candidates only; or
    • Pomalidomide and dexamethasone if member has failed ≥2 prior therapies and demonstrated disease progression within 60 days; or
  • As a single-agent for the maintenance treatment of disease. 

Ninlaro® PA Form

Onureg^® (Azacitidine) Approval Criteria [Acute Myeloid Leukemia (AML) Diagnosis]: 

• A diagnosis of AML; and
• Used as maintenance therapy in members who have achieved first complete remission (CR) or complete remission with incomplete blood count recovery (CRi) following intensive induction chemotherapy; and
• Member is unable to complete intensive curative therapy.

Opdivo® (Nivolumab) Approval Criteria [Adjuvant Treatment of Melanoma]:   

• All of the following criteria must be met for approval:
  • Patient has complete resection of melanoma; AND 
  • Diagnosis of stage IIIB/C melanoma following complete resection; AND
  • Nivolumab must be used as a single-agent; AND
  • Dose as follows:
    • Single-agent: 240mg every two weeks 
    • Maximum duration of 1 year.  

Opdivo^® (Nivolumab) Approval Criteria [Esophageal Squamous Cell Carcinoma (ESCC) or Esophageal or Gastroesophageal Junction (GEJ) Cancer Diagnosis]:

• Diagnosis of unresectable advanced or metastatic ESCC; and
  • Used in the first-line setting; and
  • Used in combination with 1 of the following:
    • Fluoropyrimidine- and platinum-based chemotherapy; OR
    • Ipilimumab; OR
• Diagnosis of esophageal or GEJ cancer; AND
  • Member has received preoperative chemoradiation; AND
  • Member underwent R0 (complete) resection and has residual disease; AND
  • As a single agent; OR
• Palliative therapy for members who are not surgical candidates or have unresectable locally advanced, recurrent, or metastatic disease; AND
  • Human epidermal receptor 2 (HER2)-negative disease; 
    • In first-line therapy; AND
      • In combination with oxaliplatin and fluorouracil or capecitabine; AND
      • Adenocarcinoma pathology; OR
    • In second-line or greater therapy; AND
      • As a single agent; AND
      • Squamous cell pathology. 

Opdivo® (Nivolumab) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• Diagnosis of NSCLC; and 
• First-line therapy for recurrent, advanced, or metastatic disease, meets the following:
  • No epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberrations; and
  • Used in combination with ipilimumab; and 
  • Given in combination with 2 cycles of platinum-doublet chemotherapy; and
  • Expresses programmed death ligand 1 (PD-L1) >1%; or
• For first-line therapy for resectable disease (>4cm or node positive), meeting the following:
  • Used in the neoadjuvant setting in combination with platinum-doublet chemotherapy for up to 3 treatment cycles; or
• Second-line therapy for metastatic disease, meets the following:
  • Tumor histology is 1 of the following: 
    • Adenocarcinoma; or
    • Squamous cell; or
    • Large cell; and
  • Disease progression on or after platinum-containing chemotherapy (e.g., cisplatin, carboplatin); and
  • The patient has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Keytruda^® (pembrolizumab)]; and
  • As a single-agent; and
  • Dose as follows: 240mg every 2 weeks or 480mg every 4 weeks.

Opdivo® (Nivolumab) Approval Criteria [Small Cell Lung Cancer Diagnosis]: 

• All of the following criteria must be met for approval: 
  • One of the following criteria is met:
    • Disease relapsed within six months of initial chemotherapy; OR
    • Disease is progressive on initial chemotherapy; AND  
  • Nivolumab must be used as a single-agent or in combination with ipilimumab; AND
  • The patient has not previously failed other PD-1 inhibitors (i.e. Keytruda® (pembrolizumab)]. 

Opdivo® (Nivolumab) Approval Criteria [Hodgkin Lymphoma Diagnosis]:

• All of the following criteria must be met for approval: 
  • Diagnosis of relapsed or refractory classical Hodgkin lymphoma; AND
    • Exception: lymphocyte-predominant Hodgkin lymphoma   
  • Nivolumab must be used as a single-agent; AND
  • The patient has not previously failed other PD-1 inhibitors [i.e. Keytruda® (pembrolizumab)]. 

Opdivo® (Nivolumab) Approval Criteria [Head and Neck Cancer]:  

• A diagnosis of recurrent or metastatic head and neck cancer; AND
• Squamous cell histology; AND
• Patient has received prior platinum containing regimen (cisplatin or carboplatin); AND
• The patient has not previously failed other PD-1 inhibitors [e.g., Keytruda® (pembrolizumab)]; AND
• Dose as follows: 240mg every two weeks or 480mg every four weeks.

 Opdivo® (Nivolumab) Approval Criteria [Hepatocellular Carcinoma (HCC) Diagnosis]:

• Member must have unresectable disease and is not a transplant candidate; or 
• Metastatic disease or extensive liver tumor burden; and
• Must meet 1 of the following:
  • If used as first-line therapy, must be used as single-agent; and
    • Ineligible for tyrosine kinase inhibitors or anti-angiogenic agents; or
  • If used as second-line or greater therapy, may be used as single-agent or in combination with ipilimumab; and
    • Must not have failed other checkpoint inhibitors.

Opdivo® (Nivolumab) Approval Criteria [Colorectal Cancer Diagnosis]:

• Diagnosis of unresectable or metastatic colorectal cancer; AND
• Tumor is microsatellite-instability high (MSI-H) or mismatch repair deficient (dMMR).

Opdivo^® (Nivolumab) Approval Criteria [Mesothelioma Diagnosis]:

• Diagnosis of malignant pleural mesothelioma that cannot be surgically removed; and
• Used as first-line therapy; and
• Used in combination with ipilimumab.

Opdivo® (Nivolumab) Approval Criteria [Renal Cell Carcinoma(RCC) Diagnosis]:

• Member has not previously failed other PD-1 inhibitors [e.g., Keytruda^® (pembrolizumab)]; and
• Used in 1 of the following settings:
  • For nivolumab monotherapy:
    • Diagnosis of relapsed or surgically unresectable stage IV disease; and
    • Failed prior therapy with 1 of the following medications:
      • Sunitinib; or
      • Sorafenib; or
      • Pazopanib; or
      • Axitinib; or
  • For nivolumab use in combination with ipilimumab:
    •   Diagnosis of relapsed or surgically unresectable stage IV disease in the initial treatment of members with intermediate or poor risk, previously untreated, advanced RCC; or
  • For nivolumab use in combination with cabozantinib:
    • Diagnosis of relapsed or surgically unresectable stage IV disease in the initial treatment of members with advanced RCC; and
• Dose as follows:
  • Single-agent: 240mg every 2 weeks or 480mg every 4 weeks; or
  • In combination with ipilimumab: nivolumab 3mg/kg followed by ipilimumab 1mg/kg on the same day, every 3 weeks for a maximum of 4 doses, then nivolumab 240mg every 2 weeks or 480mg every 4 weeks thereafter. 

Opdivo® (Nivolumab) Approval Criteria [Unresectable of Metastatic Melanoma Diagnosis]:

• All of the following criteria must be met for approval:
  • Diagnosis of unresectable or metastatic melanoma; AND
  • Nivolumab must be used as a single-agent, or in combination with ipilimumab:
    • As first-line therapy for untreated melanoma; OR
    • As second-line or subsequent therapy for documented disease progression while receiving or since completing most recent therapy:
      • If the patient has not previously failed other PD-1 inhibitors [i.e. Keytruda® (pembrolizumab)]; AND
      • Dose as follows:
    • Single-agent: 240mg every two weeks or 480mg every four weeks; OR
    • In combination with ipilimumab: 1mg/kg, followed by ipilimumab on the same day, every three weeks for four doses, then 240mg every two weeks or 480mg every four weeks.

Opdivo^® (Nivolumab) Approval Criteria [Urothelial Bladder Cancer Diagnosis]:

• Diagnosis of urothelial carcinoma; and
  • Member has undergone radical resection; and
  • Disease is at high risk of recurrence; or
• Diagnosis of metastatic or unresectable locally advanced disease; and
  • Used as second-line or greater therapy; and
  • Previous failure of a platinum-containing regimen; and
  • Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Keytruda^® (pembrolizumab)].

Opdivo^® (Nivolumab) Approval Criteria [Gastric Cancer Diagnosis]:

• Diagnosis of advanced or metastatic disease; and
• Used in combination with fluoropyrimidine- and platinum-containing chemotherapy.

Prior Authorization Form - Opdivo

Orgovyx™ (Relugolix) Approval Criteria [Prostate Cancer Diagnosis]:

• Diagnosis of advanced prostate cancer; and
• A patient-specific, clinically significant reason why the member cannot use Eligard^® (leuprolide acetate), Firmagon^® (degarelix), and Lupron Depot^® (leuprolide acetate) must be provided [reason(s) must address each medication]; and
• A quantity limit of 30 tablets per 30 days will apply. Upon meeting approval criteria, a quantity limit override will be approved for the day 1 loading dose of 360mg.

Prior Authorization

Padcev^® (Enfortumab) Approval Criteria [Urothelial Cancer Diagnosis]:

• Diagnosis of locally advanced or metastatic urothelial cancer; AND
• Previously received a programmed death 1 (PD-1) or programmed death ligand 1 (PD-L1) inhibitor and a platinum-containing chemotherapy in the neoadjuvant/adjuvant, locally advanced, or metastatic setting. 

Padcev® PA Form

Pemazyre™ (Pemigatinib) Approval Criteria [Cholangiocarcinoma Diagnosis]:

• Diagnosis of unresectable locally advanced or metastatic cholangiocarcinoma; AND
• Must have failed 1 or more prior therapies; AND
• Disease is positive for a fibroblast growth factor receptor 2 (FGFR2) fusion or other FGFR rearrangement.

Pemfexy™ (Pemetrexed) Approval Criteria:

• An FDA approved diagnosis; AND
• A patient-specific, clinically significant reason the member cannot use Alimta® (pemetrexed) must be provided.

Prior Authorization Form - Pemfexy

Perjeta® (Pertuzumab) Approval Criteria (Medical Billing Only):    

Perjeta^® (Pertuzumab) Approval Criteria [Colorectal Cancer (CRC) Diagnosis]:

• Diagnosis of human epidermal receptor type 2 (HER2)-positive CRC; AND
• RAS and BRAF mutation negative; AND
• Used in combination with trastuzumab; AND
• Used in 1 of the following settings:
  • If first-line therapy, member should not be a candidate for intensive therapy; OR
  • For the treatment of advanced or metastatic disease following disease progression.   

Perjeta^® (Pertuzumab) Approval Criteria [Breast Cancer Diagnosis]: 

• Positive expression of Human Epidermal Receptor Type 2 (HER2); AND
• Used in 1 of the following settings: 
  • Metastatic breast cancer who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease:
    • Used in combination with trastuzumab and chemotherapy; OR
  • Neoadjuvant treatment of patients with locally advanced, inflammatory, or early stage breast cancer (either greater than 2cm in diameter or node positive): 
    • Used in combination with trastuzumab chemotherapy; OR  
  • Adjuvant systemic therapy for patients with node positive, HER2-positive tumors or high-risk node negative members [tumor >1cm; tumor 0.5 to 1cm with histologic or nuclear grade 3; estrogen receptor (ER)/progesterone receptor (PR) negative; or age <35]: 
    • Used in combination with trastuzumab chemotherapy; OR
    • Used in combination with trastuzumab and docetaxel following AC; OR
    • Used in combination with TCH (docetaxel/carboplatin/trastuzumab); OR 
    • Used in combination with trastuzumab following neoadjuvant therapy with paclitaxel or docetaxel and carboplatin/trastuzumab/pertuzumab.

Prior Authorization Form - Perjeta

Phesgo™ (Pertuzumab/Trastuzumab/Hyaluronidase-zzxf) Approval Criteria [Breast Cancer Diagnosis]:

• Human epidermal growth factor receptor 2 (HER2)-positive disease; AND
• Used in 1 of the following settings:
  a. Neoadjuvant treatment of members with locally advanced, inflammatory, or early stage breast cancer; OR
  b.    Adjuvant treatment of members with early stage breast cancer; OR
  c.    In combination with docetaxel for members with metastatic disease.

Pluvicto^® (Lutetium Lu 177 Vipivotide Tetraxetan) Approval Criteria [Prostate Cancer Diagnosis]:

• Diagnosis of prostate-specific membrane antigen (PSMA)-positive metastatic castration-resistant prostate cancer (mCRPC); AND
• Member must have been treated with androgen receptor pathway inhibition and taxane-based chemotherapy.

Pluvicto® PA Form

Polivy™ (Polatuzumab Vedotin-piiq) Approval Criteria [Diffuse Large B-Cell Lymphoma (DLBCL) or High Grade B-Cell Lymphoma Diagnosis]: 

• Relapsed/refractory DLBCL or high grade B-cell lymphoma after at least 2 prior therapies; AND
• Used in combination with bendamustine and rituximab; AND
• Member is not a candidate for transplant.  

Prior Authorization Form  

Provenge® (Sipuleucel-T) Approval Criteria (Medical Billing Only):

• A diagnosis of metastatic, castration-resistant prostate cancer; AND
• Member must be asymptomatic or minimally symptomatic; AND
• Member must not have hepatic metastases; AND
• Member must have a life expectancy of greater than six months; AND
• Approvals will be for the duration of three months at which time additional authorization may be granted if the prescriber documents that the member has not shown evidence of progressive disease while on sipuleucel-T therapy.

Prior Authorization Form - Provenge

Qinlock™ (Ripretinib) Approval Criteria [Gastrointestinal Stromal Tumor (GIST) Diagnosis]:

• Diagnosis of advanced GIST; AND
• Previously received ≥3 kinase inhibitors, including imatinib; AND
• Used as a single-agent.
  

Retevmo^® (Selpercatinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]: 

• Diagnosis of recurrent, advanced, or metastatic NSCLC; and
• Rearranged during transfection (RET) fusion-positive tumor; and
• As a single-agent. 

• Adult and pediatric members 12 years of age and older; and
• As a single-agent; and
• Diagnosis of advanced or metastatic disease with either:
  • Rearranged during transfection (RET)-mutant medullary thyroid cancer (MTC) requiring systemic therapy; or
  • RET fusion-positive thyroid cancer requiring systemic therapy and member is radioactive iodine-refractory (if radioactive iodine is appropriate). 

Rezurock™ (Belumosudil) Approval Criteria [Graft-Versus-Host Disease (GVHD) Diagnosis]:

• Diagnosis of chronic GVHD; and
• Failure of at least 2 prior lines of systemic therapy; and
• Member must be 12 years of age or older. 

Riabni™ (Rituximab-arrx) Approval Criteria: 

• An FDA approved diagnosis; and
• A patient-specific, clinically significant reason why the member cannot use Rituxan^® (rituximab) must be provided. 

Rozlytrek® (Entrectinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:  

• Diagnosis of metastatic NSCLC; AND
• ROS1-positive.

Rozlytrek® (Entrectinib) Approval Criteria [Solid Tumor Diagnosis]:

• Diagnosis of solid tumors; AND
• Member must be 12 years of age or older; AND
• Neurotrophic tyrosine receptor kinase (NTRK) gene fusion without a known acquired resistance mutation; AND
• Metastatic or not a surgical candidate; AND
• Progressed following treatment or have no satisfactory alternative therapy. 

Prior Authorization Form - Rozlytrek

Rubraca® (Rucaparib) Approval Criteria [Ovarian, Fallopian Tube, or Primary Peritoneal Cancer Diagnosis]:

• Treatment of Advanced Recurrent/Refractory Disease:
  a.    Diagnosis of recurrent or refractory disease; AND
  b.    Previous treatment with ≥2 prior lines of chemotherapy (prior chemotherapy regimens should be documented on the prior authorization request); AND
  c.    Disease is associated with a deleterious or suspected deleterious BRCA mutation; AND
  d.    Used as a single-agent; OR
  
  
• Maintenance Treatment of Advanced Disease:
  a.    Diagnosis of advanced or recurrent disease; AND
  b.    Disease must be in a complete or partial response to platinum-based chemotherapy; AND
  c.    Used as a single-agent.

• Diagnosis of metastatic CRPC; AND
• Member must have failed previous first-line therapy; AND
  
• Used as a single-agent except for the following:
         a.    Concomitant treatment with a gonadotropin-releasing hormone (GnRH) analog or prior history of bilateral orchiectomy; AND
  
• Disease must be positive for a mutation in BRCA1 or BRCA2.
  
  

Ruxience™ (Rituximab-pvvr) Approval Criteria:

• An FDA approved diagnosis; AND
• A patient-specific, clinically significant reason why the member cannot use Rituxan® (rituximab) must be provided. 

Prior Authorization Form

Rybrevant^® (Amivantamab-vmjw) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• Diagnosis of locally advanced or metastatic NSCLC; and
• Tumor exhibits epidermal growth factor receptor (EGFR) exon 20 insertion mutations; and
• Disease has progressed on or after platinum-based chemotherapy; and
• As a single agent.

Rybrevant® PA Form

Sarclisa® (Isatuximab-irfc) Approval Criteria [Multiple Myeloma Diagnosis]:  

• Diagnosis of relapsed or refractory multiple myeloma (RRMM) and;
• Used in 1 of the following settings: 
  • Used in combination with pomalidomide and dexamethasone after ≥2 prior therapies [previous treatment must have included lenalidomide and a proteasome inhibitor (PI)]; or
  • Used in combination with carfilzomib and dexamethasone after 1 to 3 prior therapies.

Prior Authorization Form  

Scemblix^® (Asciminib) Approval Criteria [Chronic Myeloid Leukemia (CML) Diagnosis]:

• Diagnosis of Philadelphia chromosome-positive (Ph+) CML in chronic phase; and
  • Previously treated with ≥2 tyrosine kinase inhibitors (TKIs); or 
  • Frontline or subsequent therapy in members with the T315I mutation.

Scemblix® PA Form

Sprycel® (Dasatinib) Approval Criteria [Philadelphia Chromosome Positive (Ph+) Acute Lymphoblastic Leukemia (ALL) Diagnosis]:

• Member must have 1 of the following:  
  • Upfront therapy (including induction and consolidation) in combination with multi-agent chemotherapy or as a single-agent; OR  
  • Maintenance therapy including:
    •  In combination with vincristine and prednisone, with or without methotrexate and mercaptopurine; OR
    • Post-hematopoietic stem cell transplant; OR   
  • Relapsed/refractory as a single-agent or in combination with multi-agent chemotherapy.  

Sprycel® (Dasatinib) Approval Criteria [Chronic Myeloid Leukemia (CML) Diagnosis]:

• Member must have 1 of the following:
  • Chronic, accelerated, or blast phase CML; OR
  • Post-hematopoietic stem cell transplant.  

Sprycel® (Dasatinib) Approval Criteria [Soft Tissue Sarcoma – Gastrointestinal Stromal Tumors (GIST) Diagnosis]:

• Member must have all of the following:
  • Progressive disease and failed imatinib, sunitinib, or regorafenib; AND  
  • PDGFRA D842V mutation.  

Prior Authorization Form

Stivarga^® (Regorafenib) Approval Criteria [Colorectal Cancer (CRC) Diagnosis]:

• Diagnosis of metastatic, recurrent, or unresectable CRC; AND
• Previous treatment with a fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy; AND
• Previous treatment with an anti-vascular endothelial growth factor (VEGF) therapy; AND
  • If RAS wild-type disease, previously treated with an anti-epidermal growth factor receptor (EGFR) therapy.

Stivarga^® (Regorafenib) Approval Criteria [Gastrointestinal Stromal Tumor (GIST) Diagnosis]:

• Diagnosis of locally advanced unresectable or metastatic GIST; AND
• Previously treated with imatinib and sunitinib.

Stivarga^® (Regorafenib) Approval Criteria [Hepatocellular Carcinoma (HCC) Diagnosis]:

• Diagnosis of HCC; AND
• Previous treatment with sorafenib.

Tabrecta™ (Capmatinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]: 

• Diagnosis of recurrent, advanced, or metastatic NSCLC; and
• Mesenchymal-epithelial transition (MET) exon 14 skipping positive tumor; and
• As a single-agent. 

Tafinlar® (Dabrafenib) Approval Criteria [Anaplastic Thyroid Cancer (ATC) Diagnosis]:  

• Diagnosis of ATC; AND
• Locally advanced or metastatic disease; AND
• BRAF V600E mutation; AND
• No satisfactory locoregional treatment options.  

Tafinlar® (Dabrafenib) Approval Criteria [Melanoma Diagnosis]:

• All of the following criteria must be met for approval:
  • Diagnosis of unresectable or metastatic melanoma; AND
  • BRAF V600E or V600K mutation detected by an FDA-approved test; AND
    • Not indicated for wild-type BRAF melanoma    
  • Dabrafenib must be used as a single-agent or in combination with trametinib (Mekinist®); AND
  • One of the following is met:
    • Used as first-line therapy; OR
    • Used as second-line therapy or subsequent therapy and patient has an ECOG performance status of 0 to 2.  

Tafinlar® (Dabrafenib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• All of the following criteria must be met for approval:
  • BRAF V600E or V600K mutation detected by an FDA-approved test; AND
    • Not indicated for wild-type BRAF NSCLC 
  • Dabrafenib must be used as a single-agent or in combination with trametinib (Mekinist®) 
  • Diagnosis of refractory or metastatic disease. 

Prior Authorization Form - Tafinlar

Tagrisso™ (Osimertinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• Diagnosis of NSCLC; and  
  • As adjuvant therapy following tumor resection in members with epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 L858R mutations; or
• Diagnosis of metastatic NSCLC; and
  • EGFR T790M mutation-positive disease; or
  • EGFR exon 19 deletions or exon 21 L858R mutations. 

Prior Authorization Form - Tagrisso

Tarceva® (Erlotinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:  

• A diagnosis of NSCLC; AND
• Recurrence or metastatic disease; AND
• Epidermal growth factor receptor (EGFR) mutation detected; AND
• Erlotinib must be used as a single-agent only. 

Tarceva® (Erlotinib) Approval Criteria [Pancreatic Cancer Diagnosis]:

• A diagnosis of pancreatic cancer; AND
• Locally advanced unresectable or metastatic disease; AND
• Erlotinib must be used as a first-line agent only; AND
• Erlotinib must be used in combination with gemcitabine.

Tarceva® (Erlotinib) Approval Criteria [Kidney Cancer Diagnosis]:

• A diagnosis of kidney cancer; AND
• Non-clear cell type; AND
• Relapsed disease or for surgically unresectable stage IV disease; AND
• Erlotinib must be used as a single-agent only.

Tarceva® (Erlotinib) Approval Criteria [Bone Cancer – Chordoma Diagnosis]:

• A diagnosis of bone cancer – chordoma; AND
• Recurrent disease; AND
• Erlotinib must be used as a single-agent only.

Tarceva® (Erlotinib) Approval Criteria [Pancreatic Adenocarcinoma Diagnosis]:

• A diagnosis of pancreatic adenocarcinoma; AND
• Locally advanced unresectable disease or metastatic disease; AND
• Erlotinib must be used in combination with gemcitabine. 

Prior Authorization Form - Tarceva

Tasigna® (Nilotinib) Approval Criteria [Chronic Myeloid Leukemia (CML) Diagnosis]:  

• Member must have 1 of the following:  
  • Newly diagnosed chronic, accelerated, or blast phase CML; OR
  • Philadelphia Chromosome Positive (Ph+) CML chronic phase (CP) resistant or intolerant to prior tyrosine-kinase inhibitor (TKI) therapy; OR
  • Post-hematopoietic stem cell transplantation.  

Prior Authorization Form - Tasigna

Tazverik™ (Tazemetostat) Approval Criteria [Epithelioid Sarcoma Diagnosis]:  

• A diagnosis of metastatic or locally advanced epithelioid sarcoma; AND
• Member is not eligible for complete resection; AND
• Member must be 16 years of age or older.  

• Treatment of adult members with relapsed/refractory disease; and
• EZH2 mutation detected; and
• Member must have received 2 lines of therapy or as subsequent therapy with no satisfactory alternative treatment options.

Prior Authorization Form - Tazverik

Tecartus™ (Brexucabtagene Autoleucel) Approval Criteria [Lymphoma Diagnosis]: 

• Diagnosis of mantle cell lymphoma; and
• Relapsed or refractory disease; and
• Health care facilities must be on the certified list to administer chimeric antigen receptor (CAR) T-cells and must be trained in the management of cytokine release syndrome (CRS), neurologic toxicities, and comply with the risk evaluation and mitigation strategy (REMS) requirements. 

Tecartus^® (Brexucabtagene Autoleucel) Approval Criteria [Acute Lymphoblastic Leukemia (ALL) Diagnosis]:

• Diagnosis of ALL; and
• Relapsed or refractory disease; and
• Health care facilities must be on the certified list to administer chimeric antigen receptor (CAR) T-cells and must be trained in the management of cytokine release syndrome (CRS), neurologic toxicities, and comply with the risk evaluation and mitigation strategy (REMS) requirements.

Tecentriq® (Atezolizumab) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:  

• A diagnosis of non-squamous NSCLC; AND 
  • First-line therapy for metastatic disease; AND
  • The member does not have epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK), ROS1, BRAF, MET exon 14 skipping, or RET mutations; AND 
  • Atezolizumab must be used in combination with bevacizumab, paclitaxel, AND carboplatin (maximum of 6 cycles) or in combination with paclitaxel (protein bound) and carboplatin; AND 
  • Atezolizumab and bevacizumab may be continued after the above combination in members without disease progression (applies to the bevacizumab/paclitaxel/carboplatin regimen); OR
• A diagnosis of NSCLC; AND
  • For first-line therapy for metastatic disease:
    • Used as a single-agent; AND
    • The member does not have EGFR, ALK, ROS1, BRAF, MET exon 14 skipping, or RET mutations; AND
    • High programmed death ligand-1 (PD-L1) expression determined by 1 of the following:
      • PD-L1 stained ≥50% of tumor cells (TC≥50%); OR
      • PD-L1 stained tumor-infiltrating immune cells (IC) covering ≥10% of the tumor area (IC≥10%); OR
  • Subsequent therapy for metastatic disease; AND
    • Atezolizumab must be used as a single-agent only; or
• Diagnosis of stage 2 or 3A NSCLC; and
  • Member has undergone resection and completed platinum-based chemotherapy; and
  • PD-L1 expression of ≥1% of TC.

Tecentriq® (Atezolizumab) Approval Criteria [Urothelial Carcinoma]:

• A diagnosis of locally advanced or metastatic urothelial carcinoma; AND
• Progressed on or following platinum containing chemotherapy or in cisplatin ineligible patients.

Tecentriq® (Atezolizumab) Approval Criteria [Small Cell Lung Cancer (SCLC) Diagnosis]:  

• A diagnosis of SCLC; AND
• First-line therapy; AND
• Extensive-stage disease; AND
• Atezolizumab must be used in combination with carboplatin and etoposide.

Tecentriq® (Atezolizumab) Approval Criteria [Hepatocellular Carcinoma (HCC) Diagnosis]:

• Diagnosis of advanced, unresectable, or metastatic disease; AND
• Used in combination with bevacizumab; AND
• Member has not received prior systemic therapy.

Tecentriq® (Atezolizumab) Approval Criteria [Melanoma Diagnosis]:

• Unresectable or metastatic disease; AND
• BRAF V600 mutation-positive; AND
• In combination with cobimetinib and vemurafenib.

Prior Authorization 

Tepmetko^® (Tepotinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• Diagnosis of advanced, metastatic, or unresectable NSCLC; and
• Mesenchymal-epithelial transition (MET) exon 14 skipping positive tumor; and
• As a single-agent. 

Tibsovo® (Ivosidenib) Approval Criteria [Acute Myeloid Leukemia (AML) Diagnosis]:  

• Newly diagnosed AML in members 75 years of age or older or in adult members who have comorbidities that preclude use of intensive chemotherapy; AND
  • As a single-agent; AND
  • IDH1 mutation; OR  
• Relapsed/refractory AML; AND
  • As a single-agent; AND
  • IDH1 mutation.  

Prior Authorization Form - Tibsovo

Tibsovo^® (Ivosidenib) Approval Criteria [Cholangiocarcinoma Diagnosis]:

• Diagnosis of locally advanced or metastatic cholangiocarcinoma; and
• An isocitrate dehydrogenase-1 (IDH1) mutation; and
• Member has received prior treatment for this diagnosis.

Tivdak^® (Tisotumab Vedotin-tftv) Approval Criteria [Cervical Cancer Diagnosis]:

• Diagnosis of recurrent or metastatic cervical cancer; AND
• Disease has progressed on or after chemotherapy.

Tivdak® PA Form

Trodelvy® (Sacituzumab Govitecan-hziy) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of triple-negative breast cancer; AND
• Unresectable locally advanced or metastatic disease; AND
• Member must have received ≥2 prior therapies, at least 1 of which was for metastatic disease.

Trodelvy^® (Sacituzumab Govitecan-hziy) Approval Criteria [Urothelial Cancer Diagnosis]: 

• Diagnosis of unresectable locally advanced or metastatic disease; and
• Member must have previously received a platinum-containing chemotherapy; and
• Member must have previously received either a programmed death receptor-1 (PD-1) or programmed death-ligand 1 (PD-L1) inhibitor     

Truseltiq™ (Infigratinib) Approval Criteria [Cholangiocarcinoma Diagnosis]:

• Diagnosis of unresectable, locally advanced or metastatic cholangiocarcinoma; and
• Presence of fibroblast growth factor receptor 2 (FGFR2) fusion or other rearrangement; and
• Disease has progressed on at least 1 prior systemic therapy; and
• As a single agent.

Prior Authorization

Truxima® (Rituximab-abbs) Approval Criteria:

• An FDA approved diagnosis; AND
• A patient-specific, clinically significant reason why the member cannot use Rituxan® (rituximab) must be provided.  

Prior Authorization Form

Tukysa™ (Tucatinib) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of advanced unresectable or metastatic breast cancer; AND
• Used in combination with trastuzumab and capecitabine; AND
• Disease is human epidermal growth factor receptor 2 (HER2)-positive; AND
• Following progression of ≥1 prior anti-HER2 regimen(s) in the metastatic setting.

Prior Authorization Form

Turalio™ (Pexidartinib) Approval Criteria [Soft Tissue Sarcoma – Pigmented Villonodular Synovitis (PVNS)/Tenosynovial Giant Cell Tumor (TGCT) Diagnosis]:   

• Member must not be a candidate for surgery; AND
• Pexidartinib must be used as a single-agent only. 

Prior Authorization Form - Turalio

Ukoniq™ (Umbralisib) Approval Criteria [Marginal Zone Lymphoma (MZL) Diagnosis]: 

• Diagnosis of MZL; and
• Relapsed or refractory disease; and
• Member must have received at least 1 prior anti-CD20-based regimen.

• Diagnosis of FL; and
• Relapsed or refractory disease; and
• Member must have received at least 3 prior lines of systemic therapy.

Venclexta® (Venetoclax) Approval Criteria [Acute Myeloid Leukemia (AML) Diagnosis]:   

• Member meets 1 of the following:
  • Member must be 75 years of age or older; OR  
  • If the member is younger than 75 years of age, they must be unable to tolerate intensive induction chemotherapy; AND  
• As first-line therapy or in relapsed/refractory disease; AND  
• Must be used in combination with azacitidine, or decitabine, or low-dose cytarabine (LDAC). 

Venclexta™ (Venetoclax) Approval Criteria [Mantle Cell Lymphoma (MCL) Diagnosis]:  

• As second-line or subsequent therapy; AND 
• As a single-agent only.  

Venclexta™ (Venetoclax) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:

• Untreated disease in combination with obinutuzumab for a maximum duration of 12 months; OR
• Relapsed/refractory disease in combination with rituximab or as a single-agent.  

Prior Authorization Form - Venclexta

Verzenio™ (Abemaciclib) Approval Criteria [Breast Cancer Diagnosis]:   

• Diagnosis of advanced or metastatic breast cancer; and
  • Hormone receptor positive disease; AND
  • Human epidermal growth factor receptor 2 (HER2)-negative disease; AND
    • Used in 1 of the following settings:
      • In combination with an aromatase inhibitor as initial endocrine-based therapy for postmenopausal women; OR
      • In combination with fulvestrant with disease progression following endocrine therapy; OR
      • As monotherapy for disease progression following endocrine therapy and prior chemotherapy; OR     
• Diagnosis of early-stage breast cancer; AND
  
  • Hormone receptor positive disease; AND
  • HER2-negative disease; AND
  • Node-positive disease high risk for recurrence with Ki-67 ≥20%; AND
  • Used as adjuvant treatment in combination with endocrine therapy.

Prior Authorization Form

Vitrakvi® (Larotrectinib) Approval Criteria [Solid Tumors With Neurotrophic Receptor Tyrosine Kinase (NTRK) Gene Fusion Diagnosis]:   

• Diagnosis of a solid tumor with a NTRK gene fusion without a known acquired resistance mutation; AND
• Disease is metastatic or surgical resection (or radioactive iodine refractory if thyroid carcinoma) is contraindicated; AND
• Documentation of no satisfactory alternative treatments or progression following acceptable alternative treatments. 

Prior Authorization Form

Vizimpro® (Dacomitinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:   

• A diagnosis of metastatic NSCLC; AND
• Member has not received prior epidermal growth factor receptor (EGFR) therapy for metastatic disease; AND
• Member must meet 1 of the following:
  • EGFR exon 19 deletion; OR  
  • Exon 21 L858R substitution mutation. 

Prior Authorization Form

Welireg™ (Belzutifan) Approval Criteria:

• Diagnosis of von Hippel-Landau (VHL) disease; AND
• Diagnosis of either renal cell carcinoma, central nervous system hemangioblastomas, or pancreatic neuroendocrine tumor; AND
• Does not require immediate surgery.

Welireg™ PA Form

Xalkori® (Crizotinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:  

• A diagnosis of metastatic NSCLC (first-line or subsequent therapy); AND
• Anaplastic lymphoma kinase (ALK) or ROS1 positivity; OR  
• MET amplification; AND
• Crizotinib must be used as a single-agent only. 

Xalkori® (Crizotinib) Approval Criteria [Soft Tissue Sarcoma – Inflammatory Myofibroblastic Tumor (IMT) with Anaplastic Lymphoma Kinase (ALK) Translocation Diagnosis]:

• A diagnosis of soft tissue sarcoma – IMT; AND
• Anaplastic lymphoma kinase (ALK) positivity; AND
• Crizotinib must be used as a single-agent only. 

• Members 1 to 21 years of age:
  • Diagnosis of systemic ALCL that is anaplastic lymphoma kinase (ALK)-positive; and
  • Relapsed or refractory disease; or
• Members older than 21 years of age:
  • Diagnosis of systemic ALCL that is ALK-positive; and
  • Second-line or initial palliative intent therapy and subsequent therapy.

Prior Authorization Form - Xalkori

Xofigo® (Radium-223 Dichloride) Approval Criteria (Pharmacy Billing Only):

• A diagnosis of metastatic, castration-resistant prostate cancer; AND
• Member must have symptomatic bone metastases; AND
• Member must not have known visceral metastatic disease; AND
• Prescriber must verify radium-223 is not to be used in combination with chemotherapy; AND
• Member must have an absolute neutrophil count ≥ 1.5 x 109/L, platelet count ≥ 100 x 109/L, and hemoglobin ≥10 g/dL; AND
• Approvals will be for the duration of three months at which time additional authorization may be granted if the prescriber documents the following:  
  • The member has not shown evidence of progressive disease while on radium-223 dichloride therapy; AND
  • Member must have an absolute neutrophil count ≥ 1 x 109/L, platelet count ≥ 100 x 109/L (radium-223 dichloride should be delayed 6 to 8 weeks otherwise). 

Prior Authorization Form - Xofigo

Xospata® (Gilteritinib) Approval Criteria [Acute Myeloid Leukemia (AML) Diagnosis]:

• Relapsed/refractory AML; AND
• FLT3 mutation; AND
• As a single-agent. 

Prior Authorization Form - Xospata

Xpovio^® (Selinexor) Approval Criteria [Multiple Myeloma Diagnosis]:

• Diagnosis of relapsed or refractory multiple myeloma (RRMM); and
• Used in 1 of the following settings:
  • In combination with dexamethasone in members who have received ≥4 prior therapies including refractory disease to ≥2 proteasome inhibitors (PIs), ≥2 immunomodulatory agents, and an anti-CD38 monoclonal antibody; or
  • Used in combination with bortezomib and dexamethasone in members who have failed at least 1 prior therapy.

• Diagnosis of relapsed/refractory DLBCL, not otherwise specified, including DLBCL arising from follicular lymphoma; and
• Member has received ≥2 prior lines of systemic therapy.  

Xpovio® PA Form

Xtandi® (Enzalutamide) Approval Criteria (Pharmacy Billing Only):

• A diagnosis of castration-resistant prostate cancer; AND
• Approvals will be for the duration of three months at which time additional authorization may be granted if the prescriber documents that the member has not shown evidence of progressive disease while on enzalutamide therapy.

Xtandi® (Enzalutamide) Approval Criteria [Castration-Sensitive Prostate Cancer (CSPC) Diagnosis]:

• Diagnosis of metastatic CSPC.

Prior Authorization Form - Xtandi

Yervoy® (Ipilimumab) Approval Criteria [Adjuvant Treatment of Melanoma]: 

• All of the following criteria must be met for approval:
  • Patient has complete resection of melanoma with lymphadenectomy; AND
  • Patient has Stage III disease with regional nodes of greater than 1 mm and no in-transit metastasis; AND
  • Ipilimumab must be used as a single-agent;  AND
  • Maximum doses of 10mg/kg will apply. 

Yervoy^® (Ipilimumab) Approval Criteria [Hepatocellular Carcinoma (HCC) Diagnosis]:

• Member must have unresectable disease and is not a transplant candidate; or
• Metastatic disease or extensive liver tumor burden; and
• Used as second-line or greater therapy; and
• Used in combination with nivolumab; and
• Must not have failed other checkpoint inhibitors.

Yervoy® (Ipilimumab) Approval Criteria [Colorectal Cancer Diagnosis]:

• Diagnosis of unresectable or metastatic colorectal cancer; AND
• Tumor is microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR); AND
• Used in combination with nivolumab.

Yervoy^® (Ipilimumab) Approval Criteria [Mesothelioma Diagnosis]:

• Diagnosis of malignant pleural mesothelioma that cannot be surgically removed; and
• Used as first-line therapy; and
• Used in combination with nivolumab.

Yervoy^® (Ipilimumab) Approval Criteria [Esophageal Squamous Cell Carcinoma (ESCC) Diagnosis]:

• Diagnosis of unresectable advanced or metastatic ESCC; AND
  • Used in the first-line setting; AND
  • Used in combination with nivolumab.

• Diagnosis of recurrent, advance, or metastatic non-small cell lung cancer (NSCLC); and
  • First-line therapy for metastatic disease; and
  • No epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) genomic tumor aberrations; and
  • Given in combination with nivolumab; and
  • Expresses programmed death ligand (PD-L1) >1%; or
  • Given in combination with 2 cycles of platinum-doublet chemotherapy.

Yervoy® (Ipilimumab) Approval Criteria [Renal Cell Carcinoma (RCC) Diagnosis]:

• A diagnosis of relapsed or surgically unresectable stage IV disease in the initial treatment of patients with intermediate or poor risk, previously untreated, advanced RCC; AND
• Ipilimumab must be used in combination with nivolumab; AND
• The patient has not failed previous PD-1 inhibitors [e.g., Keytruda® (pembrolizumab)]; AND
• Dose as follows: nivolumab 3mg/kg followed by ipilimumab 1mg/kg on the same day, every three weeks for a maximum of four doses, then nivolumab 240mg every two weeks or 480mg every four weeks.

Yervoy® (Ipilimumab) Approval Criteria [Small Cell Lung Cancer Diagnosis]: 

• All of the following criteria must be met for approval: 
  • One of the following criteria is met: 
    • Disease relapsed within six months of initial chemotherapy; OR
    • Disease is progressive on initial chemotherapy; AND
  • Used in combination with nivolumab. 

Yervoy® (Ipilimumab) Approval Criteria [Unresectable or Metastatic Melanoma Diagnosis]:

• All of the following criteria must be met for approval:
  • Ipilimumab is used in combination with nivolumab as:  
    • First-line therapy; OR 
    • Second-line or subsequent therapy for disease progression if nivolumab was not previously used; AND
  • Ipilimumab is used as a single-agent for one of the following:  
    • First-line therapy as a single course of four treatments; OR
    • Second-line or subsequent lines of therapy as a single course of four treatments; OR
    • Retreatment, consisting of a 4-dose limit, for an individual who had no significant systemic toxicity during prior ipilimumab therapy, and whose disease progressed after being stable for greater than six months following completion of a prior course of ipilimumab, and for whom no intervening therapy has been administered; AND
  • Maximum dose of 3mg/kg will apply.  

Prior Authorization Form - Yervoy

Yescarta® (Axicabtagene Ciloleucel) Approval Criteria [Lymphoma Diagnosis]:   

• Large B-cell lymphoma [including diffuse large B cell lymphoma (DLBCL), high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma (FL)], or relapsed or refractory FL; AND
• Member must be 18 years of age or older; AND
• Relapsed or refractory disease used in 1 of the following settings:
  • After two or more lines of therapy; OR
  • After 1 line of therapy, if member is refractory to first-line chemotherapy or relapses within 12 months of first-line chemotherapy; AND
• Health care facilities must be on the certified list to administer chimeric antigen receptor (CAR) T-cells and must be trained in the management of cytokine release syndrome (CRS), neurologic toxicities, and comply with the REMS requirements.  
• For large B-cell lymphoma (including DLBCL, high grade B-cell lymphoma, and DLBCL arising from FL), member must not have primary central nervous system lymphoma.

Prior Authorization Form - Yescarta

Yonsa® (Abiraterone) Approval Criteria:  

• A diagnosis of metastatic, castration-resistant prostate cancer (CRPC); AND
• Concomitant treatment with a gonadotropin-releasing hormone (GnRH) analog or prior history of bilateral orchiectomy.  
• Abiraterone must be used in combination with a corticosteroid.   

Prior Authorization Form

Zelboraf® (Vemurafenib) Approval Criteria [Melanoma Diagnosis]:

• All of the following criteria must be met for approval: 
  • Diagnosis of unresectable or metastatic melanoma; AND
  • BRAF V600E or V600K mutation detected by an FDA-approved test; AND
    • Not indicated for wild-type BRAF melanoma 
  • Vemurafenib must be used as a single-agent or in combination with cobimetinib; AND
  • One of the following is met:
    • Used as first-line therapy; OR
    • Used as second-line therapy or subsequent therapy.  

Zelboraf® (Vemurafenib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• All of the following criteria must be met for approval:
  • BRAF V600E or V600K mutation detected by an FDA-approved test; AND
    • Vemurafenib is not indicated for wild-type BRAF NSCLC 
  • Vemurafenib must be used as a single-agent
  • Diagnosis of refractory or metastatic disease. 

Zelboraf® (Vemurafenib) Approval Criteria [Hairy-Cell Leukemia Diagnosis]:

• All of the following criteria must be met for approval: 
  • Vemurafenib must be used as a single-agent; AND
  • Vemurafenib is being used to treat disease progression following failure of purine analog therapy (i.e. pentostatin, cladribine). 

Zelboraf® (Vemurafenib) Approval Criteria [Erdheim-Chester Disease]:

• All of the following criteria must be met for approval:
  • BRAF V600E or V600K mutation detected by an FDA-approved test; AND  
  • Vemurafenib must be used as a single-agent.  

Prior Authorization Form - Zelboraf

Zejula^® (Niraparib) Approval Criteria [Ovarian, Fallopian Tube, or Primary Peritoneal Cancer Diagnosis]: 

• Single-Agent Treatment of Advanced Recurrent/Refractory Disease: 
  • Diagnosis of recurrent or refractory disease; and
  • Previous treatment with ≥3 prior lines of chemotherapy (prior chemotherapy regimens should be documented on the prior authorization request); and
  • Diagnosis is associated with homologous recombination deficiency (HRD) positive status defined by either:
    • A deleterious or suspected deleterious BRCA mutation; or
    • Genomic instability and progression >6 months after response to last platinum-based chemotherapy; and
  • Used as a single-agent; or
• Treatment of Advanced Recurrent/Refractory Disease in Combination with Bevacizumab:
  • Used in combination with bevacizumab for platinum-sensitive persistent disease or recurrence; and
  • Meets 1 of the following:
    • As immediate treatment for serially rising CA-125 in members who previously received chemotherapy, or
    • Evidence of radiographic and/or clinical relapse in members with previous complete remission and relapse ≥6 months after completing prior chemotherapy; or 
• Maintenance Treatment of Advanced Disease: 
  • Diagnosis of advanced or recurrent disease; and
  • Disease must be in a complete or partial response to platinum chemotherapy; and
  • Used as a single-agent.

Zejula® PA Form

Zepzelca™ (Lurbinectedin) Approval Criteria [Small Cell Lung Cancer (SCLC) Diagnosis]:

• Diagnosis of metastatic SCLC; and
• Used following disease progression on or after platinum-based chemotherapy.

Zirabev^® (Bevacizumab-bvzr) Approval Criteria*:

• Biosimilars and/or reference products are preferred based on the lowest net cost product(s) and may be moved to either preferred or non-preferred if the net cost changes in comparison to the reference product and/or other available biosimilar products.

*Based on the net cost in comparison to available bevacizumab products, Zirabev^® is currently available without prior authorization.

Zydelig® (Idelalisib) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]:  

• A diagnosis of Grade 1 to 2 FL; AND
• As second-line or subsequent therapy for refractory or progressive disease; AND
• Refractory to both alkylator and rituximab therapy.   

Zydelig® (Idelalisib) Approval Criteria [Gastric or Nongastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma, Nodal or Splenic Marginal Zone Lymphoma (MZL) Diagnosis]:

• As second-line or subsequent therapy for refractory or progressive disease; AND
• Refractory to both alkylator and rituximab therapy.

Zydelig® (Idelalisib) Approval Criteria [Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) Diagnosis]:

• For relapsed or refractory disease; AND
• In combination with rituximab or rituximab/bendamustine; OR
• As a single-agent.  

Prior Authorization Form - Zydelig

Zynlonta^® (Loncastuximab Tesirine-lpyl) Approval Criteria [Lymphoma Diagnosis]:

• Diagnosis of diffuse large B-cell lymphoma (DLBCL) not otherwise specified, or DLBCL arising from low grade lymphoma, or high-grade B-cell lymphoma; and
• Relapsed or refractory disease after 2 or more lines of systemic therapy; and
• If previous CD19-directed therapy was used, patient must have a biopsy that shows CD19 protein expression after completion of the CD19-directed therapy; and
• A patient-specific, clinically significant reason why tafasitamab in combination with lenalidomide is not appropriate for the member must be provided. 

Zynlonta® PA Form

Zykadia® (Ceritinib) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• A diagnosis of metastatic NSCLC; AND
• Anaplastic lymphoma kinase (ALK) positivity; AND
• Ceritinib must be used as a single-agent only.

Zykadia® (Ceritinib) Approval Criteria [Soft Tissue Sarcoma – Inflammatory Myofibroblastic Tumor (IMT) with Anaplastic Lymphoma Kinase (ALK) Translocation Diagnosis]:

• A diagnosis of soft tissue sarcoma – IMT; AND
• Anaplastic lymphoma kinase (ALK) positivity; AND
• Ceritinib must be used as a single-agent only.  

Prior Authorization Form - Zykadia

Zytiga® (abiraterone) Approval Criteria [Castration-Sensitive Prostate Cancer (CSPC) Diagnosis]:

• A diagnosis of metastatic, high-risk, CSPC; AND
• Abiraterone must be used in combination with a corticosteroid.

Prior Authorization Form - Zytiga