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.
• 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
• Approvals will be for 1 dose per member per lifetime.

Abecma® PA Form

Adcetris^® (Brentuximab Vedotin) Approval Criteria [Classical Hodgkin Lymphoma (cHL) Diagnosis]:

• For members 18 years of age or older:
  • In previously untreated Stage III or IV disease in combination with doxorubicin, vinblastine, and dacarbazine; or
  • In relapsed/refractory disease after failure of ≥2 multi-agent chemotherapy regimens in non-autologous stem cell transplant (SCT) candidates or after failure of autologous SCT as a single-agent; or
  • In relapsed/refractory disease if not previously used in combination with nivolumab, bendamustine, or multi-agent chemotherapy; or
  • Consolidation following autologous SCT in members at high risk of relapse or progression; or
• For members 2 to 21 years of age:
  • Diagnosis of previously untreated cHL; and
  • Stage IIB with bulky disease, Stage IIIB, or Stage IV per Ann Arbor staging system; and
  • Used in combination with doxorubicin, vincristine, etoposide, prednisone, and cyclophosphamide (AVE-PC); and
  • Maximum of (5) 21-day cycles will be approved.

Adstiladrin^® (Nadofaragene Firadenovec-vncg) Approval Criteria [Non-Muscle Invasive Bladder Cancer (NMIBC) Diagnosis]:

• Diagnosis of NMIBC with carcinoma in situ (CIS) with or without papillary tumors; and
• High-risk disease that was unresponsive to prior Bacillus Calmette-Guérin (BCG) therapy. 

Adstiladrin® Prior Authorization Form

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

Akeega^® (Niraparib/Abiraterone Acetate) Approval Criteria [Castration-Resistant Prostate Cancer (CRPC) Diagnosis]:

• Diagnosis of metastatic CRPC; and
• Presence of deleterious or suspected deleterious BRCA mutation based upon an FDA-approved test; and
• Used in conjunction with prednisone; and
• Used in conjunction with a gonadotropin-releasing hormone (GnRH) analog or prior history of bilateral orchiectomy; and
• Member has not progressed on prior abiraterone therapy.

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; or
• Diagnosis of resected NSCLC (tumors ≥4cm or node positive); and
  • ALK positivity; and
  • Used as adjuvant treatment; and
  • As a single agent only.

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; AND
• As a single agent. 

 Prior Authorization Form - Alunbrig

Anktiva^® (Nogapendekin Alfa Inbakicept-pmln) Approval Criteria [Non-Muscle Invasive Bladder Cancer (NMIBC) Diagnosis]:

• Diagnosis of NMIBC with carcinoma in situ (CIS); and
• Cancer is unresponsive to initial Bacillus Calmette-Guerin (BCG) therapy; and
• Will be used in conjunction with BCG; and
• Initial approval will be for 6 induction doses; and
• Subsequent requests must indicate if the member has had a complete response to induction dosing; and
  • A second induction course (6 doses) may be approved if a complete response is not achieved at month 3; and
• If complete response is achieved, maintenance dosing may be approved in 6-month intervals up to a maximum of 37 months of treatment.

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]:

• Diagnosis of ALL; and
• Used as a component of multi-agent chemotherapy; and
• 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.

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

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

• Diagnosis of locally advanced or metastatic NSCLC; and
• ROS1-positive; and
• Used as a single agent.

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

• A diagnosis of unresectable or metastatic GIST; AND
• Member must be 18 years of age or older; and
• Member has a PDGFRA exon 18 mutation (including PDGFRA D842V mutations).  

Ayvakit® (Avapritinib) Approval Criteria [Advanced Systemic Mastocytosis (AvdSM) Diagnosis]:

• Diagnosis of advanced systemic mastocytosis, including members with aggressive systemic mastocytosis, systemic mastocytosis with an associated hematologic neoplasm, OR mast cell leukemia; and
• Member must be 18 years of age or older; and
• Platelet count ≥50 x 10⁹/L.

Ayvakit^® (Avapritinib) Approval Criteria [Indolent Systemic Mastocytosis (ISM) Diagnosis]:

• Diagnosis of ISM; and
• Member must be 18 years of age or older; and
• Platelet count ≥50 x 10⁹/L.

Prior Authorization Form - Ayvakit

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 FGFR3 genetic mutation; AND  
• Disease has progressed on or after at least 1 line of systemic therapy; and
  • Member has received prior treatment with a programmed death 1 (PD-1) or programmed death ligand 1 (PD-L1) inhibitor.

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 

Beleodaq® (Belinostat) Approval Criteria [Adult T-Cell Leukemia/ Lymphoma Diagnosis]:

• As a single agent in relapsed/refractory disease.
  

Beleodaq® (Belinostat) Approval Criteria [Anaplastic Large Cell Lymphoma (ALCL), Primary Cutaneous Diagnosis]:

• As a single agent for primary treatment or relapsed refractory with multifocal lesions, or cutaneous ALCL with regional nodes.
  

Beleodaq® (Belinostat) Approval Criteria [Peripheral T-Cell Lymphoma (PTCL) Diagnosis]:

• As a single agent in relapsed/refractory disease.

Beleodaq® (Belinostat) Approval Criteria [T-Cell Lymphoma, Extranodal NK/T-Cell Lymphoma, Nasal Type Diagnosis]:

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

Beleodaq® PA Form

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

Besremi^® (Ropeginterferon Alfa-2b-njft) Approval Criteria [Polycythemia Vera (PV) Diagnosis]:

• Diagnosis of PV; AND
• Used as a single agent.

Blincyto® (Blinatumomab) Approval Criteria [Acute Lymphoblastic Leukemia (ALL) Diagnosis]:

• Member must have 1 of the following:
  
  • Relapsed/refractory Philadelphia chromosome negative (Ph-) ALL; or
    
  • Relapsed/refractory Philadelphia chromosome positive (Ph+) ALL after failure of ≥2 tyrosine kinase inhibitors (TKIs); or
    
  • Ph- ALL as consolidation in adolescent/young adults or members younger than 65 years of age without substantial comorbidity with persistent or late clearance minimal residual disease positive (MRD+) following a complete response to induction; and
    
• As a single agent.
  

Blincyto® PA Form

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.

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

• Diagnosis of metastatic NSCLC; and
• BRAF V600E mutation; and
• Used in combination with binimetinib.

Prior Authorization Form - Braftovi®

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

• Diagnosis of large B-cell lymphoma; and
• One of the following:
  • Refractory disease to frontline chemoimmunotherapy; or
  • Relapse within 12 months of frontline chemoimmunotherapy; or
  • Relapse after frontline chemoimmunotherapy and member is not eligible for hematopoietic stem cell transplantation (HSCT) due to comorbidity or age; or
  • Relapsed or refractory disease after 2 or more lines of systemic therapy; and
• Member does not have primary central nervous system (CNS) lymphoma; 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; and
• Approvals will be for 1 dose per member per lifetime.

Breyanzi® PA 

Brukinsa^® (Zanubrutinib) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]:

• Diagnosis of FL; and
• Third line or subsequent therapy for no response, relapsed, or progressive disease; and
• Used in combination with obinutuzumab.

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.

Brukinsa^® (Zanubrutinib) Approval Criteria [Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) Diagnosis]:

• Diagnosis of CLL/SLL.

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; or
• In combination with obinutuzumab.

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

Carvykti™ (Ciltacabtagene Autoleucel) 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, 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
    • Member 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; 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
• Approvals will be for 1 dose per member per lifetime.

Carvykti PA Form

Columvi™ (Glofitamab-gxbm) Approval Criteria [Lymphoma Diagnosis]:

• Diagnosis of relapsed or refractory diffuse large B-cell lymphoma (DLBCL) not otherwise specified, including large B-cell lymphoma (LBCL) arising from follicular lymphoma; and
• Has received ≥2 lines of systemic therapy; and
• Will receive a single dose of obinutuzumab for pre-treatment purposes.

Columvi™ PA Form

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.   

Copiktra^® (Duvelisib) Approval Criteria [Peripheral T-Cell Lymphomas (PTCL) Diagnosis]:

• Diagnosis of PTCL; and
• 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  

Cotellic^® (Cobimetinib) Approval Criteria [Histiocytic Neoplasm Diagnosis]:

• Diagnosis of a histiocytic neoplasm; and
• Member must be 18 years of age or older; and
• Used as a single agent.

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:
    • Dexamethasone and bortezomib; or
    • Carfilzomib and dexamethasone; or
    • Dexamethasone and lenalidomide; or
    • Cyclophosphamide, bortezomib, and dexamethasone; or
    • Pomalidomide and dexamethasone* [*previous therapy for this combination must include lenalidomide and a proteasome inhibitor (PI)]; or
    • 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

Elahere™ (Mirvetuximab Soravtansine-gynx) Approval Criteria [Ovarian, Fallopian Tube, or Primary Peritoneal Cancer Diagnosis]:

• Diagnosis of platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer; and
• Tumor is folate receptor alpha (FRα) positive; and
• Member has received 1 to 3 prior systemic treatment regimens.

Elahere™ Prior Authorization

Elrexfio™ (Elranatamab-bcmm) Approval Criteria [Multiple Myeloma Diagnosis]:

• Diagnosis of relapsed or refractory multiple myeloma; and
• Member has received at least 4 prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody; and
• Health care facilities must be trained in the management of cytokine release syndrome (CRS), neurologic toxicities, and comply with the risk evaluation and mitigation strategy (REMS) requirements.

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.

Epkinly™ (Epcoritamab-bysp) Approval Criteria [Lymphoma Diagnosis]:

• Diagnosis of relapsed or refractory diffuse large B-cell lymphoma (DLBCL) not otherwise specified, including DLBCL arising from indolent lymphomas and/or high-grade B-cell lymphomas; and
• Has received ≥2 lines of systemic therapy.

Epkinly™ PA Form

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

Erleada (Apalutamide) Approval Criteria [Castration-Resistant Prostate Cancer (CRPC) Diagnosis]:

• Diagnosis of non-metastatic CRPC; or
• Diagnosis of non-metastatic prostate cancer with 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.

Erleada (Apalutamide) Approval Criteria [Castration-Sensitive Prostate Cancer (CSPC) Diagnosis]:

• Diagnosis of metastatic CSPC; and
• Concomitant treatment with a luteinizing hormone-releasing hormone (LHRH) agonist/antagonist or prior history of bilateral orchiectomy. 

Prior Authorization 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;and
• Members who are new to treatment with Exkivity^® will generally not be approved.

Exkivity® PA Form

Folotyn® (Pralatrexate) Approval Criteria [Adult T-Cell Leukemia/ Lymphoma Diagnosis]:

• As a single agent in relapsed/refractory disease.
  

Folotyn® (Pralatrexate) Approval Criteria [Anaplastic Large Cell Lymphoma (ALCL), Primary Cutaneous Diagnosis]:

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

Folotyn® (Pralatrexate) Approval Criteria [Peripheral T-Cell Lymphoma (PTCL) Diagnosis]:

• As a single agent in relapsed/refractory disease.
  

Folotyn® (Pralatrexate) Approval Criteria [Primary Cutaneous Lymphomas – Mycosis Fungoides (MF)/Sézary Syndrome (SS) Diagnosis]:

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

Folotyn® (Pralatrexate) Approval Criteria [T-Cell Lymphoma, Extranodal NK/T-Cell Lymphoma, Nasal Type Diagnosis]:

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

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

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

Fotivda® PA Form

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; AND
• As a single agent.  

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

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 acalabrutinib, 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 [Diffuse Large B-Cell Lymphoma (DLBCL) Diagnosis]:

• Diagnosis of relapsed or refractory DLBCL not otherwise specified, including large B-cell lymphoma (LBCL) arising from follicular lymphoma; and
• Used as lymphoid depletion pretreatment prior to glofitamab; and
• Member must meet criteria for glofitamab; and
• Dosing will be 1,000mg as a single dose 7 days prior to start of glofitamab.

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; or
• Third line or subsequent therapy for FL in members with no response, relapsed, or progressive disease; and
  • Used in combination with zanubrutinib.

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

Neulasta^® (Pegfilgrastim), Nyvepria^® (Pegfilgrastim-apgf), Stimufend^® (Pegfilgrastim-fpgk), and Udenyca^® (Pegfilgrastim-cbqv) Approval Criteria:

• An FDA approved diagnosis; and
• A patient-specific, clinically significant reason why the member cannot use Fulphila^® (pegfilgrastim-jmdb), Fylnetra^® (pegfilgrastim-pbbk), Neulasta^® Onpro^® (pegfilgrastim), or Ziextenzo^® (pegfilgrastim-bmez) 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; and
• Neulasta^® Onpro^® (pegfilgrastim) will be covered as a medical only benefit without prior authorization.

Nivestym^® (Filgrastim-aafi) and Releuko^® (Filgrastim-ayow) Approval Criteria:

• An FDA approved diagnosis; and
• A patient-specific, clinically significant reason why the member cannot use Granix^® (tbo-filgrastim), Neupogen^® (filgrastim), or Zarxio^® (filgrastim-sndz) 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.

Rolvedon^® (Eflapegrastim-xnst) Approval Criteria:

• An FDA approved diagnosis; and
• A patient-specific, clinically significant reason why the member cannot use Fulphila^® (pegfilgrastim-jmdb), Fylnetra^® (pegfilgrastim-pbbk), Neulasta^® Onpro^® (pegfilgrastim), or Ziextenzo^® (pegfilgrastim-bmez) must be provided; and
• Neulasta^® Onpro^® (pegfilgrastim) will be covered as a medical only benefit without prior authorization. 

Ryzneuta® (Efbemalenograstim Alfa-vuxw) Approval Criteria:

• An FDA approved diagnosis; and
• A patient-specific, clinically significant reason why the member cannot use Fulphila® (pegfilgrastim-jmdb), Fylnetra® (pegfilgrastim-pbbk), Neulasta® Onpro® (pegfilgrastim), or Ziextenzo® (pegfilgrastimbmez) must be provided; and
• Neulasta® Onpro® (pegfilgrastim) will be covered as a medical only benefit without prior authorization.

Neulasta/Nivestym/Nyvepria/Releuko/Rolvedon/Stimufend/Udenyca PA Form

Medical billing only

Halaven (eribulin) Approval Criteria [Recurrent or Metastatic Breast Cancer Diagnosis]:

• Diagnosis of recurrent or metastatic breast cancer; and
• Previously received at least 2 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; or
• In combination with trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive disease that is:
  • Hormone receptor (HR)-negative; or
  • HR-positive with or without endocrine therapy; or
• As a single-agent for HER2-negative disease that is:
  • HR-negative; or
  • HR-positive with visceral crisis or endocrine therapy refractory.

Halaven (eribulin) Approval Criteria [Liposarcoma Diagnosis]:

• Diagnosis of unresectable or metastatic liposarcoma; and
• Previously received anthracycline-containing chemotherapy regimen.
• Authorizations will be for the duration of 6 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.

Hepzato Kit™ (Melphalan) Approval Criteria [Uveal Melanoma Diagnosis]:

• Diagnosis of metastatic uveal melanoma; and
• Presence of hepatic metastases affecting <50% of the liver; and
• No other extrahepatic metastases; or
• Presence of extrahepatic metastases limited to the bone, lymph nodes, subcutaneous tissue, and/or lung that is amenable to resection or radiation.

Hepzato Kit™ PA Form

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
• Preferred trastuzumab products include Herzuma^® (trastuzumab-pkrb), Kanjinti^® (trastuzumab-anns), and Trazimera™ (trastuzumab-qyyp). Authorization of non-preferred trastuzumab products [Herceptin^® (trastuzumab), Herceptin Hylecta™ (trastuzumab/ hyaluronidase-oysk), Ogivri^® (trastuzumab-dkst], or Ontruzant^® (trastuzumab-dttb)will also require a patient-specific, clinically significant reason why the member cannot use the preferred trastuzumab products [ Herzuma^® (trastuzumab-pkrb), Kanjinti^® (trastuzumab-anns), 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, lapatinib, or tucatinib; 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
• Preferred trastuzumab products include Herzuma^® (trastuzumab-pkrb), Kanjinti^® (trastuzumab-anns), and Trazimera™ (trastuzumab-qyyp). Authorization of non-preferred trastuzumab products [Herceptin^® (trastuzumab), Ogivri^® (trastuzumab-dkst), or Ontruzant^® (trastuzumab-dttb)] will also require a patient-specific, clinically significant reason why the member cannot use the preferred trastuzumab products [Herzuma^® (trastuzumab-pkrb), Kanjinti^® (trastuzumab-anns) 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
• Preferred trastuzumab products include Herzuma^® (trastuzumab-pkrb), Kanjinti^® (trastuzumab-anns), and Trazimera^® (trastuzumab-qyyp). Authorization of non-preferred trastuzumab products [Herceptin^® (trastuzumab), Ogivri^® (trastuzumab-dkst), or Ontruzant^® (trastuzumab-dttb)] will also require a patient-specific, clinically significant reason why the member cannot use the preferred trastuzumab products [Herzuma^® (trastuzumab-pkrb), Kanjinti^® (trastuzumab-anns), 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 female members; 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]:

• Failure of 1 or more lines of therapy1; AND
• Member must be 1 year of age or older; AND
• For members younger than 12 years of age:
  • The member’s current body surface area (BSA) must be provided; AND
  • Requests for use of the 70mg capsule formulation will require a patient-specific, clinically significant reason why the member cannot use the 70mg/mL oral suspension formulation.

Imbruvica® (Ibrutinib) Approval Criteria [B-Cell Lymphoma Diagnosis]:

• As second-line or subsequent therapy for members with a diagnosis of B-cell lymphoma [including diffuse large B-cell lymphomas, human immunodeficiency virus (HIV)-related B-cell lymphomas, post-transplant lymphoproliferative disorders, and high-grade B-cell lymphoma].

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

• As second-line or subsequent therapy; or
• Used in combination with rituximab prior to induction therapy; or
• Used as a component of aggressive induction therapy; or
• Used as a maintenance therapy following aggressive induction therapy or hematopoietic stem cell transplant (HSCT).

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

• Diagnosis of hairy cell leukemia; and
• As third-line or subsequent therapy for refractory or progressive disease.

Imbruvica^® (Ibrutinib) Approval Criteria [Primary Central Nervous System (CNS) Lymphoma Diagnosis]:

• Diagnosis of primary CNS lymphoma; and
• Member is not a candidate for or is intolerant to high-dose methotrexate according to the prescriber; or
• As a second-line or subsequent therapy for refractory or progressive disease.

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 [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 [Biliary Tract Cancer Diagnosis]:

• Diagnosis of locally advanced or metastatic biliary tract cancer; and
• Used in combination with gemcitabine and cisplatin.

Imfinzi^® (Durvalumab) Approval Criteria [Hepatocellular Carcinoma (HCC) Diagnosis]:

• Diagnosis of unresectable HCC; and
• Used in combination with tremelimumab-actl; or
• As a single agent. 

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; OR
• Diagnosis of metastatic NSCLC; AND
  • No epidermal growth factor (EGFR) mutation or anaplastic lymphoma kinase (ALK) genomic tumor aberrations; AND
  • Used in combination with tremelimumab-actl and platinum-based chemotherapy.

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

Imfinzi Prior Authorization Form  

Imjudo^® (Tremelimumab-actl) Approval Criteria [Hepatocellular Carcinoma (HCC) Diagnosis]:

• Diagnosis of unresectable HCC; AND
• Used in combination with durvalumab; AND
• Will be approved for a maximum of 1 dose per treatment plan per member.

Imjudo^® (Tremelimumab-actl) Approval Criteria [Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• Diagnosis of metastatic NSCLC; AND
• No epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), or ROS1 mutations; AND
• Used in combination with durvalumab and platinum-based chemotherapy; AND
• Will be approved for a maximum of 5 doses per treatment plan per member.

Imjudo PA 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. 

Iwilfin™ (Eflornithine) Approval Criteria [Neuroblastoma Diagnosis]:

• Diagnosis of high-risk neuroblastoma (HRNB); and
• Member has had at least a partial response to prior multiagent, multimodality therapy including anti-GD2 immunotherapy; and
• Used as a single agent to reduce the risk of relapse for a maximum of 2 years; and
• Member’s recent body surface area (BSA) must be provided.

Iwilfin™ PA Form

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. 

Jakafi® PA Form

Jaypirca^® (Pirtobrutinib) Approval Criteria [Chronic Lymphocytic/Small Lymphocytic Lymphoma (CLL/SLL) Diagnosis]:

• Diagnosis of CLL/SLL; and
• Has received ≥2 lines of systemic therapy, including a Bruton’s kinase (BTK) inhibitor and a BCL-2 inhibitor.

Jaypirca™ (Pirtobrutinib) Approval Criteria [Mantle Cell Lymphoma (MCL) Diagnosis]:

• Diagnosis of MCL; AND
• Relapsed or refractory disease after ≥2 lines of systemic therapy; AND
• Previous treatment must have included a Bruton’s tyrosine kinase (BTK) inhibitor (e.g., acalabrutinib, ibrutinib, zanubrutinib).

Jaypirca PA Form

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

• Diagnosis of non-metastatic upper urinary tract tumor; and
• Must be a single, residual, low-grade, low-volume (5 to 15mm) tumor; and
• Member is not a candidate for nephroureterectomy; and
• 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.  

Jelmyto® PA Form

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

• Used as a single agent; and 
  • 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; or
• Used in combination with carboplatin and paclitaxel; and
  • Diagnosis of primary advanced or recurrent endometrial cancer; and
  • Mismatch repair deficient (dMMR) or microsatellite instability-high (MSI-H) disease.

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 six 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. 

Kadcyla^® (Ado-Trastuzumab Emtansine) Approval Criteria [Early Stage or Locally Advanced Breast Cancer Diagnosis]:

• Diagnosis of early stage or locally advanced breast cancer; and
• Human epidermal growth factor receptor 2 (HER2)-positive; and
• Used as adjuvant treatment in members with residual invasive disease after neoadjuvant therapy with taxane and trastuzumab-based treatment; and
• Maximum duration of a total of 14 cycles.

Prior Authorization Form - Kadcyla

Kepivance^® (Palifermin) Approval Criteria Oral Mucositis Associated with Autologous Stem Cell Transplant Conditioning Diagnosis]:

• Diagnosis of hematologic malignancy; and
• Undergoing autologous stem cell transplantation; and
• Using a preparative regimen predicted to result in ≥Grade 3 mucositis in >50% of patients; and
• The preparative regimen and a reference for the preparative regimen must be provided; and
  • Single dose melphalan 200mg/m² is not included as an appropriate preparative regimen due to lack of efficacy of palifermin with this regimen.

Kepivance® PA Form

Keytruda^® (Pembrolizumab) Approval Criteria [Biliary Tract Cancer (BTC) Diagnosis]:

• Diagnosis of locally advanced unresectable or metastatic BTC; and
• Used in combination with gemcitabine and cisplatin.

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]:

• Diagnosis of recurrent or metastatic cervical cancer; and
  • Tumor must express programmed death ligand 1 (PD-L1) [combined positive score (CPS) ≥1)]; and
  • Member has not previously failed other programmed death 1 (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.
• Diagnosis of FIGO Stage III-IV cervical cancer; and
  • Used in combination with concomitant chemotherapy and radiation.

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

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

Keytruda^® (Pembrolizumab) Approval Criteria [Cutaneous Squamous Cell Carcinoma (cSCC) Diagnosis]:

• Diagnosis of recurrent or metastatic disease; and
• Not curable by radiation or surgery.

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

• Member has not previously failed other programmed death 1 (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) Carcinoma 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)]; and
• For first-line therapy:
  • In combination with platinum- and fluoropyrimidine-based chemotherapy; or
• For second-line or greater therapy:
  • Following disease progression after 1 or more prior lines of systemic therapy; and
  • Tumor must be squamous cell histology; and
  • Used as a single agent; 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
    • Used in combination with trastuzumab, fluoropyrimidine- and platinum-containing chemotherapy.
    • Tumor is positive for expression of programmed death ligand 1 (PD-L1) with a combined positive score (CPS) ≥1; or
  • HER2-negative disease; and
    • Used in combination with fluoropyrimidine- and platinum-containing chemotherapy. 

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

• Used in first-line or recurrent setting; and
• Squamous cell histology; and
• If used in the recurrent setting, member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Opdivo^® (nivolumab)].

Keytruda^® (Pembrolizumab) Approval Criteria [Hepatocellular Carcinoma (HCC) Diagnosis]:

• Diagnosis of relapsed or progressive HCC; and
• Member must have been previously treated with sorafenib; and
• Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Opdivo^® (nivolumab)].

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

• 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
    • Used as a single agent; or
    • Exception: lymphocyte-predominant Hodgkin lymphoma; or
    • Used in Second-line or subsequent systemic therapy in combination with gemcitabine, vinorelbine, and liposomal doxorubicin; or
• For pediatric members:
  • Used as a single agent; and
  • Diagnosis of refractory cHL; or
  • Relapsed disease after ≥2 therapies

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

• Member meets 1 of the following:
  • Adjuvant treatment of adult and pediatric members 12 years of age or older with stage 2B, 2C, or 3 melanoma following complete resection; or
  • Diagnosis of unresectable or metastatic melanoma; and
• Used as a single agent; and
• Member meets 1 of the following:
  • Used as first-line therapy; or
  • Used as second-line therapy or subsequent therapy for disease progression if not previously used; and
• Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Opdivo^® (nivolumab)]; and
• For adjuvant treatment of melanoma, approvals will be for a maximum duration of 1 year.

Keytruda^® (Pembrolizumab) Approval Criteria [Merkel Cell Carcinoma (MCC) Diagnosis]:

• Diagnosis of recurrent, locally advanced, or metastatic MCC; and
• No history of prior systemic chemotherapy; and
• Used as a single agent; and
• Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Opdivo^® (nivolumab)].

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

• Diagnosis of metastatic NSCLC; and
• Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Opdivo^® (nivolumab)]; and
• Tumor proportion scores for programmed death ligand 1 (PD-L1) expression as follows:
  • As a single agent, first-line: ≥1%; or
  • First-line in combination: No expression required; or
  • As a single agent, second-line: ≥1%; and
• Member meets 1 of the following:
  • Previously untreated, metastatic squamous NSCLC in combination with carboplatin and either paclitaxel or nab-paclitaxel; or
  • Previously untreated, metastatic non-squamous NSCLC in combination with pemetrexed and carboplatin; or
  • New diagnosis as first-line therapy (member has not received chemotherapy to treat disease) if:
    • Tumor does not express sensitizing epidermal growth factor receptor (EGFR) mutations or anaplastic lymphoma kinase (ALK) translocations; or
  • Used as a single agent for disease progression on or after platinum-containing chemotherapy (i.e., cisplatin, carboplatin):
    • Members with EGFR-mutation-positive tumors 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 (examples of drugs for EGFR-mutation-positive tumors: osimertinib, erlotinib, afatinib, or gefitinib); and
    • Members 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 (examples of drugs for ALK-mutation-positive tumors: crizotinib, ceritinib, or alectinib).

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 [Nonmetastatic Non-Small Cell Lung Cancer (NSCLC) Diagnosis]:

• Diagnosis of stage 3 NSCLC; and
  • Ineligible for surgery or definitive chemoradiation; and
  • Tumor proportion scores for programmed death ligand 1 (PD-L1) expression ≥1%; and
  • Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Opdivo^® (nivolumab)]; or
• Diagnosis of stage 1B (T2a >4cm), stage 2, or stage 3A NSCLC; and
  • Used as adjuvant treatment following resection and platinum-based chemotherapy; or
• Diagnosis of resectable (tumors ≥4cm or node positive) NSCLC; and
  • Used as neoadjuvant treatment in combination with platinum-containing chemotherapy; and
  • Continued as a single agent as adjuvant treatment after surgery.

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

• 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]:

• Diagnosis of PMBCL; and
• Member must have refractory disease or relapsed after 2 or more prior lines of therapy; and
• Authorizations will not be granted for members who require urgent cytoreduction; and
• Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Opdivo^® (nivolumab)]. 

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

• Diagnosis of new or recurrent stage 4 clear-cell RCC; and
  • Member has not received previous systemic therapy for advanced disease; and
  • Must be used in combination with axitinib or lenvatinib; and
  • Member has not previously failed other programmed death 1 (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 [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 programmed death 1 (PD-1) inhibitors [e.g., Opdivo^® (nivolumab)].

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 [Urothelial Carcinoma Diagnosis]:

• Member must have 1 of the following:
  • As a single agent for locally advanced or metastatic urothelial carcinoma with disease progression during or following platinum-containing chemotherapy; or
  • As a single agent within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy; or
  • As a single agent frontline for members with locally advanced or metastatic urothelial carcinoma who are ineligible for cisplatin-containing chemotherapy; and
    • Cisplatin ineligibility is defined as:
      • Baseline creatinine clearance of <60mL/min; or
      • ECOG performance status of 2; or
      • Class III heart failure; or
      • Grade 2 or greater peripheral neuropathy; or
      • Grade 2 or greater hearing loss; and
  • In combination with enfortumab vedotin-ejfv for locally advanced or metastatic urothelial carcinoma; and
• Member has not previously failed other programmed death 1 (PD-1) inhibitors [i.e., Opdivo^® (nivolumab)].

Prior Authorization Form - Keytruda

Kimmtrak^® (Tebentafusp-tebn) Approval Criteria [Uveal Melanoma Diagnosis]:

• Diagnosis of unresectable or metastatic uveal melanoma; AND
• Positive expression of HLA-A*02:01 genotype. 

Kimmtrak® PA Form

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. 

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

• Diagnosis of recurrent, advanced, or metastatic NSCLC; AND
• Presence of KRAS G12C mutation in tumor or plasma specimen as determined by an FDA approved test; AND
• Member has received at least 1 prior systemic therapy; AND
• As a single agent.

Krazati PA Form

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)] or 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; and
• Approvals will be for 1 dose per member per lifetime.  

 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; AND
• Approvals will be for 1 dose per member per lifetime.   

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 mismatch repair proficient (pMMR) or is not microsatellite instability-high (MSI-H); 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
• Used in the first-line setting; AND
• No epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), or ROS1 mutations; AND
• Used in 1 of the following setting: AND
  • Used as a single agent; AND
    • High programmed death ligand 1 (PD-L1) expression [tumor proportion score (TPS) ≥50%]; OR
  • Used in combination with platinum-based chemotherapy; AND
    • No requirement for PD-L1 expression.

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.

Lonsurf® PA Form

Loqtorzi™ (Toripalimab-tpzi) Approval Criteria [Nasopharyngeal Carcinoma (NPC) Diagnosis]:

• Diagnosis of metastatic or recurrent, locally advanced NPC; and
  • Used in the first-line setting; and
  • Used in combination with cisplatin and gemcitabine; and
  • Dose as follows:
    • 240mg every 3 weeks; and
    • Maximum duration of 2 years; or
• Diagnosis of previously treated recurrent unresectable or metastatic NPC; and
  • Disease has progressed on or following a platinum-containing chemotherapy; and
  • Used as a single agent; and
  • Dose as follows:
    • 3mg/kg every 2 weeks.

Loqtorzi™ PA Form

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). 
• Initial approvals will be for six months.

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

Lunsumio™ (Mosunetuzumab-axgb) Approval Criteria [Follicular Lymphoma (FL) Diagnosis]:

• Diagnosis of FL; AND
• Relapsed or refractory disease after ≥2 lines of systemic therapy. 

Lunsumio PA Form

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]:   

• 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
• Used in 1 of the following settings:
  • 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; OR                                                   
  • Used in combination with abiraterone and prednisone (or prednisolone); AND
    • Disease must be positive for a deleterious or suspected deleterious BRCA mutation.

Prior Authorization Form - Lynparza

Lytgobi^® (Futibatinib) Approval Criteria [Intrahepatic Cholangiocarcinoma Diagnosis]:

• Diagnosis of unresectable, locally advanced, or metastatic intrahepatic cholangiocarcinoma; AND
• Member was previously treated with at least 1 prior therapy; AND
• Tumor is positive for fibroblast growth factor receptor 2 (FGFR2) gene fusion or rearrangement.

Lytgobi® PA Form

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 [Low-Grade Glioma (LGG) Diagnosis]:

• Diagnosis of LGG; and
• Must be a pediatric member 1 year of age or older; and
• BRAF V600E mutation; and
• Used in combination with dabrafenib. 

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.

Mekinist^® (Trametinib) Approval Criteria [Solid Tumor Diagnosis]:

• Diagnosis of metastatic solid tumor; AND
• BRAF V600E mutation; AND
• Member must be 1 year of age or older; and
• Member has progressed on prior therapies with no satisfactory alternative treatment options; AND
• Used in combination with dabrafenib. 

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.

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

• Diagnosis of metastatic NSCLC; and
• BRAF V600E 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. 
• Initial approvals will be for six months.

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

Nubeqa^® (Darolutamide) Approval Criteria [Metastatic Hormone-Sensitive Prostate Cancer (mHSPC) Diagnosis]:

• Diagnosis of mHSPC in combination with docetaxel; AND
• Concomitant treatment with a gonadotropin-releasing hormone (GnRH) analog or prior history of bilateral orchiectomy.

Nubeqa® (Darolutamide) Approval Criteria [Castration-Resistant Prostate Cancer (CRPC) Diagnosis]:

• Diagnosis of non-metastatic CRPC; AND
• Concomitant treatment with a gonadotropin-releasing hormone (GnRH) analog or prior history of bilateral orchiectomy.

Nubeqa® PA Form

Odomzo^® (Sonidegib) Approval Criteria [Basal Cell Carcinoma (BCC) Diagnosis]:

• Diagnosis of locally advanced BCC that has either:
  • Recurred following surgery or radiation therapy; or
  • Surgery or radiation is contraindicated; or
• Diagnosis of metastatic BCC. 

Ogsiveo™ (Nirogacestat) Approval Criteria [Desmoid Tumor Diagnosis]:

• Tumor is progressing, requiring systemic treatment.

Ogsiveo™ PA Form

Ojjaara (Momelotinib) Approval Criteria [Myelofibrosis (MF) Diagnosis]:

• Diagnosis of intermediate or high-risk disease (including MF, polycythemia vera, or post-essential thrombocythemia); and
• Presence of anemia.

Omisirge^® (Omidubicel-onlv) Approval Criteria:

• Member is 12 years of age or older; and
• Diagnosis of hematological malignancy; and
• Allogeneic stem cell transplant using umbilical cord blood donor source is planned; and
  • Documentation of the donor source must be provided; and
• Myeloablative conditioning regimen will be used; and
  • Documentation of the member’s conditioning regimen must be provided; and
• Will be used to reduce time to neutrophil recovery and incidence of infection.

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 Diagnosis]:   

• Member has had complete resection of melanoma; and
• Diagnosis of stage 2B, 2C, 3, or 4 melanoma following complete resection; and
• Member is 12 years of age or older; and
• Member has not previously failed other programmed death 1 (PD-1) inhibitors [e.g., Keytruda^® (pembrolizumab)]; and
• Used as a single agent; and
• Dose as follows:
  • Adult and pediatric patients ≥40kg: 240mg every 2 weeks or 480mg every 4 weeks; or
  • Pediatric patients <40kg: 3mg/kg every 2 weeks or 6mg/kg every 4 weeks; and
  • 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 in 1 of the following settings:
    • As a single-agent; or
    • In combination with brentuximab vedotin as second line or subsequent therapy after failure of autologous stem cell transplant (SCT), allogeneic SCT, or those who are transplant-ineligible; 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
  • Member is 12 years of age or older; 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: 
      • Adult and pediatric patients ≥40kg: 240mg every two weeks or 480mg every four weeks; OR
      • Pediatric patients <40kg: 3mg/kg every 2 weeks or 6mg/kg every 4 weeks; or
    • In combination with ipilimumab: 
      • Adult and pediatric patients ≥40kg: Nivolumab 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.
      • Pediatric patients <40kg: 1mg/kg, followed by ipilimumab on the same day, every 3 weeks for 4 doses, then 3mg/kg every 2 weeks or 6mg/kg every 4 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

Opdualag™ (Nivolumab/Relatlimab-rmbw) Approval Criteria [Unresectable or Metastatic Melanoma Diagnosis]:

• Diagnosis of unresectable or metastatic melanoma; AND
• Member must be 12 years of age or older; AND
• As first-line therapy; AND
• Member has not previously failed programmed death 1 (PD-1) inhibitors [e.g., Keytruda^® (pembrolizumab), Opdivo^® (nivolumab)]. 

Opdualag™ PA Form

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

Orserdu^® (Elacestrant) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of advanced or metastatic breast cancer; and
• Estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative disease; and
• Tumor is positive for ESR1-mutation; and
• Female members must be postmenopausal; and
• Has progressed after at least 1 prior endocrine therapy.

Orserdu® PA Form

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

• Diagnosis of locally advanced or metastatic urothelial cancer; AND
• Used in 1 of the following settings:
  • As a single agent and member has 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; OR
  • As a single agent and member has received at least 1 prior therapy and is ineligible for cisplatin-containing chemotherapy; OR
  • Used in combination with pembrolizumab. 
    

Padcev® PA Form

Pedmark^® (Sodium Thiosulfate) Approval Criteria [Reduction in Ototoxicity Risk Associated with Cisplatin for Solid Tumor Diagnosis]:

• Pediatric members 1 month to 18 years of age with a diagnosis of localized, non-metastatic solid tumor; AND
• An FDA approved indication to reduce the risk of ototoxicity associated with cisplatin; AND
  • Member’s cisplatin regimen must be provided (i.e., frequency of chemotherapy cycles, number of treatment days per cycle, number of chemotherapy cycles remaining); AND
• Pedmark^® will be administered as follows:
  • Starting 6 hours after completion of cisplatin infusion; OR
  • For multi-day cisplatin regimens, Pedmark^® will be administered 6 hours after each cisplatin infusion but at least 10 hours before the next cisplatin infusion; AND
• Member has a baseline serum sodium <145mmol/L.

Pedmark® 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.

Pemazyre^® (Pemigatinib) Approval Criteria [Myeloid/Lymphoid Neoplasms (MLNs) Diagnosis]:

• Diagnosis of relapsed or refractory MLNs; AND
• Disease is positive for a fibroblast growth factor receptor 1 (FGFR1) rearrangement.

Pemfexy™ (Pemetrexed; J9304) and Pemrydi RTU^® (Pemetrexed; J9324) Approval Criteria:

• An FDA approved diagnosis; AND
• A patient-specific, clinically significant reason the member cannot use Alimta® (pemetrexed; J9305), pemetrexed ditromethamine (J9323), and other preferred pemetrexed 25mg/mL solution products (J9294 - Hospira, J9296 - Accord, J9297 – Sandoz, J9314 - Teva J9322 - Bluepoint) ) that do not require prior authorization  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.

Piqray^® (Alpelisib) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of advanced or metastatic breast cancer that has progressed on or after an endocrine-based regimen in men and postmenopausal women; and
• Hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative; and
• PIK3CA-mutated disease; and
• In combination with fulvestrant. 

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]: 

• Previously untreated DLBCL not otherwise specified or high-grade B-cell lymphoma; and
  • Has an International Prognostic Index score of ≥2; and
  • Used in combination with rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CHP); or
• Relapsed/refractory DLBCL not otherwise specified or high grade B-cell lymphoma; and
  • Member is not a candidate or has no intention to proceed to hematopoietic stem cell transplant.  

Prior Authorization Form  

Provenge® (Sipuleucel-T) Approval Criteria [Castration-Resistant Prostate Cancer (CRPC) Diagnosis]:  (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
• ECOG performance status of 0 or 1; and
• Approvals will be for 1 treatment course (3 doses) per member per lifetime.

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 [Solid Tumor Diagnosis]:

• Diagnosis of locally advanced or metastatic solid tumor; AND
• Member must be 2 years of age or older; and
• Rearranged during transfection (RET) gene fusion; AND
  • Disease has progressed on or following prior systemic treatment; OR
  • There are no satisfactory alternative treatment options; AND
• 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 2 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). 

Retevmo® PA Form

Rezlidhia™ (Olutasidenib) Approval Criteria [Acute Myeloid Leukemia (AML) Diagnosis]:

• Relapsed/refractory AML; AND
  • As a single agent; AND
  • Isocitrate dehydrogenase-1 (IDH1) mutation.

Rezlidhia PA Form

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. 

Rezurock™ PA Form

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; AND
• As a single agent. 

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

• Diagnosis of solid tumors; AND
• Member must be older than 1 month of age; 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; AND
• As a single agent. 

Prior Authorization Form - Rozlytrek

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

• Maintenance Treatment of Recurrent Disease:
  
  • Diagnosis of recurrent disease; AND
  • Disease must be in a complete or partial response to platinum-based chemotherapy; AND
  • Positive for a BRCA mutation; AND
  • 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
  • As first-line therapy in combination with carboplatin and pemetrexed; or
  • As a single agent in disease that has progressed on or after platinum-based chemotherapy; or
• Tumor exhibits EGFR exon 19 deletion or exon 21 L858R mutations; and
  • As subsequent therapy in combination with carboplatin and pemetrexed after progression on osimertinib.

Rybrevant® PA Form

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 asparagine-deprivation product.

Erwinaze®/Rylaze™ 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

Aphexda® (Motixafortide) Approval Criteria:

• An FDA approved indication for use in combination with filgrastim to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in members with multiple myeloma (MM); and
• Member must have an oncology diagnosis of MM. This medication is not covered for the diagnosis of leukemia; and
• Aphexda® must be prescribed by an oncologist; and
• Member must be 18 years of age or older; and
• Aphexda® must be given in combination with the granulocyte-colony stimulating factor (G-CSF) filgrastim per package labeling; and
• A patient-specific, clinically significant reason (beyond convenience) why the member cannot use generic plerixafor must be provided; and
• The following dosing restrictions will apply (current body weight in kilograms is required):
  • Recommended dose is 1.25mg/kg actual body weight by subcutaneous injection 10 to 14 hours prior to initiation of apheresis; and
  • A second dose of Aphexda® can be administered 10 to 14 hours prior to a third apheresis if necessary; and
• Approvals will be for 2 cycles for the duration of 2 months.

Mozobil^® (Plerixafor) Approval Criteria:

• An FDA approved indication for use in combination filgrastim to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in members with non-Hodgkin’s lymphoma (NHL) or multiple myeloma (MM); and
• Member must have an oncology diagnosis of NHL or MM. This medication is not covered for the diagnosis of leukemia; and
• Mozobil^® must be prescribed by an oncologist; and
• Member must be 18 years of age or older; and
• Mozobil^® must be used in combination with the granulocyte-colony stimulating factor (G-CSF) filgrastim per package labeling; and
• The following dosing restrictions will apply (current body weight in kilograms is required):
  • Recommended dose is 0.24mg/kg (maximum dose is 40mg/day) administered 11 hours prior to apheresis for up to 4 consecutive days; or
  • For members with renal impairment (creatinine clearance ≤50mL/min), the recommended dose is 0.16mg/kg (maximum dose is 27mg/day); and
• Approvals will be for 2 cycles for the duration of 2 months.

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.

Stivarga^® (Regorafenib) Approval Criteria [Osteosarcoma Diagnosis]:

• Used for relapsed or refractory disease; AND
• Used in the second line or greater setting; AND
• Used as a single agent. 

Stivarga® PA Form

Synribo® (Omacetaxine) Approval Criteria [Chronic Myeloid Leukemia (CML) Diagnosis]:

• Member must have 1 of the following:
  
  • Primary treatment of advanced phase CML with disease progression to accelerated phase; or
    
  • Post-hematopoietic stem cell transplant in members who have relapsed; or
    
  • T315I mutation; or
    
  • Members who are intolerant or resistant to ≥2 tyrosine kinase inhibitors (TKIs); and
    
• As a single agent.
  

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 [Low-Grade Glioma (LGG) Diagnosis]:

• Diagnosis of LGG; and
• Must be a pediatric member 1 year of age or older; and
• BRAF V600E mutation; and
• Used in combination with trametinib.

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. 

Tafinlar^® (Dabrafenib) Approval Criteria [Solid Tumor Diagnosis]:

• Diagnosis of metastatic solid tumor; AND
• BRAF V600E mutation; AND
• Member must be 1 year of age or older; and
• Member has progressed on prior therapies with no satisfactory alternative treatment options; AND
• Used in combination with trametinib.

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; and
  • As a single agent; or
• Diagnosis of metastatic NSCLC; AND
  • EGFR T790M mutation-positive disease; OR
  • EGFR exon 19 deletions or exon 21 L858R mutations; AND
  • As a single agent. 
• Diagnosis of locally advanced or metastatic non-squamous NSCLC; and
  • Used as first-line treatment; and
  • EGFR exon 19 deletions or exon 21 L858R mutations; and
  • Used in combination with pemetrexed and platinum-based (cisplatin or carboplatin) chemotherapy.

Prior Authorization Form - Tagrisso

Talvey™ (Talquetamab-tgvs) Approval Criteria [Multiple Myeloma Diagnosis]:

• Diagnosis of relapsed or refractory multiple myeloma; and
• Member has received at least 4 prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody; and
• Health care facilities must be trained in the management of cytokine release syndrome (CRS), neurologic toxicities, and comply with the risk evaluation and mitigation strategy (REMS) requirements.

Talzenna^® (Talazoparib) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of recurrent or metastatic breast cancer; AND
• Human epidermal growth factor receptor 2 (HER2)-negative; AND
• Presence of BRCA1/BRCA2-germline mutated disease; AND
• Disease is hormone receptor (HR) negative or is HR positive and endocrine therapy refractory; AND
• Patient has symptomatic visceral disease; AND
• Must be used as a single-agent.

Talzenna^® (Talazoparib) Approval Criteria [Prostate Cancer Diagnosis]:

• Diagnosis of metastatic, castration-resistant prostate cancer; AND
• Disease is homologous recombination repair (HRR) gene-mutated; AND
• Used in combination with enzalutamide.

Talzenna® PA Form

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
• ECOG performance status of 0 or 1; 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; and
• Approvals will be for 1 dose per member per lifetime.

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; and
• Approvals will be for 1 dose per member per lifetime. 

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 [Alveolar Soft Part Sarcoma (ASPS) Diagnosis]:

• Diagnosis of unresectable or metastatic ASPS; AND
• Member must be 2 years of age or older.

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 

Tecvayli™ (Teclistamab-cqyv) Approval Criteria [Multiple Myeloma Diagnosis]:

• Diagnosis of relapsed or refractory multiple myeloma; AND
• Member has received ≥4 prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 antibody; AND
• Health care facilities must be trained in the management of cytokine release syndrome (CRS), neurologic toxicities, and comply with the risk evaluation and mitigation strategy (REMS) requirements.

Tecvayli PA Form

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; and
  • Member meets 1 of the following:
    • Member is 75 years of age or older; or
    • If the member is younger than 75 years of age, must be unable to tolerate intensive induction chemotherapy; and
  • As a single agent or in combination with azacitidine; and
  • Isocitrate dehydrogenase-1 (IDH1) mutation; or
• Relapsed/refractory AML; AND
  • As a single-agent; AND
  • IDH1 mutation.  

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.

Tibsovo^® (Ivosidenib) Approval Criteria [Myelodysplastic Syndromes (MDS) Diagnosis]:

• Diagnosis of relapsed or refractory MDS; and
• Presence of isocitrate dehydrogenase-1 (IDH1) mutation, as detected by an FDA approved test.

Prior Authorization Form - Tibsovo

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; OR
• Diagnosis of hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer; AND
  • Unresectable locally advanced or metastatic disease; AND
  • Member has previously received endocrine-based therapy and ≥2 additional systemic therapies in the metastatic setting.

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; and
• Members who are new to treatment with Truseltiq^® will generally not be approved.

Truseltiq™ 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.

Tukysa^® (Tucatinib) Approval Criteria [Colorectal Cancer (CRC) Diagnosis]:

• Diagnosis of RAS wild-type HER2-positve unresectable or metastatic CRC; and
• Has progressed following treatment with fluoropyrimidine, oxaliplatin, and irinotecan-based chemotherapy; and
• Used in combination with trastuzumab.

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

Tykerb^® (Lapatinib) Approval Criteria [Breast Cancer Diagnosis]:

• Diagnosis of metastatic or recurrent breast cancer; AND
• Human epidermal growth factor receptor 2 (HER2)-positive; AND
• Lapatinib must be used in combination with 1 of the following:
  • Trastuzumab; OR
  • Capecitabine; OR
  • An aromatase inhibitor (e.g., exemestane, letrozole, anastrozole) if also estrogen receptor (ER) positive.

Tykerb^® (Lapatinib) Approval Criteria [Colorectal Cancer (CRC) Diagnosis]:

• Diagnosis of unresectable, advanced, or metastatic disease; AND
• Member has human epidermal receptor 2 (HER2)-amplified disease; AND
• Member has wild-type RAS and BRAF disease; AND
• Member meets 1 of the following:
  • Has tried at least 1 chemotherapy regimen; OR
  • Is not a candidate for intensive therapy, according to the prescriber; AND
• Used in combination with trastuzumab; AND
• Member has not been previously treated with a HER2-inhibitor.

Tykerb® PA Form

Vanflyta^® (Quizartinib) Approval Criteria [Acute Myeloid Leukemia (AML) Diagnosis]:

• Newly diagnosed AML; and
• Disease is positive for FLT3 internal tandem duplication (FLT3-ITD) as detected by an FDA-approved test; and
• Will be used in 1 of the following settings:
  • In combination with standard anthracycline and cytarabine-based induction; or
  • In combination with standard cytarabine-based consolidation; or
  • As maintenance therapy following standard anthracycline and cytarabine-based induction and cytarabine-based consolidation.

Vanflyta® PA Form

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; AND
  • Used as adjuvant treatment in combination with endocrine therapy.

Prior Authorization Form

Vijoice^® (Alpelisib) Approval Criteria [PIK3CA-Related Overgrowth Spectrum (PROS) Diagnosis]:

• Adult and pediatric members 2 years of age and older; AND
• Documented PIK3CA gene mutation; AND
• Severe or life-threatening clinical manifestations of PROS.

Vijoice® PA 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; AND
•  As a single agent. 

Prior Authorization Form

Vonjo^® (Pacritinib) Approval Criteria [Myelofibrosis (MF) Diagnosis]:

• Diagnosis of intermediate or high-risk primary or secondary MF; AND
• Platelet count <50 x 10⁹/L.

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

• Diagnosis of advanced RCC; and
• Member has received at least 2 lines of systemic therapy, including a programmed death receptor-1 (PD-1) or programmed death-ligand 1 (PD-L1) inhibitor and a vascular endothelial growth factor tyrosine kinase inhibitor (VEGF-TKI); and
• As a single agent. 

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
• Member must be 1 year of age or older; AND
• Anaplastic lymphoma kinase (ALK) positivity; AND
• Crizotinib must be used as a single-agent only. 

• Members 1 year of age or older:
  • Diagnosis of systemic ALCL that is anaplastic lymphoma kinase (ALK)-positive; and
  • Relapsed or refractory disease; AND
• As a single agent. 

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). 
• Initial approvals will be for six months.

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 [Castration-Resistant Prostate Cancer (CRPC) Diagnosis]: (Pharmacy Billing Only):

• A diagnosis of castration-resistant prostate cancer. 

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

• Diagnosis of metastatic CSPC; or
• Diagnosis of non-metastatic CSPC with biochemical recurrence at high risk for metastasis (high-risk BCR).

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; and
• Approvals will be for 1 dose per member per lifetime.

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]: 

• 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
  • If used for maintenance following recurrence:
    • Must be positive for a BRCA mutation (this does not apply if used after first-line therapy); 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.

Zolinza^® (Vorinostat) Approval Criteria [Primary Cutaneous Lymphomas – Mycosis Fungoides (MF)/Sézary Syndrome (SS) Diagnosis]:

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

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) Diagnosis]:

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

Prior Authorization Form - Zydelig

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

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

Zynyz™ (Retifanlimab-dlwr) Approval Criteria [Merkel Cell Carcinoma (MCC) Diagnosis]:

• Diagnosis of metastatic or recurrent locally advanced MCC; and
• Member must be 18 years of age or older; and
• A maximum treatment duration of 24 months will apply.

Zynyz™ PA Form

Zytiga^® (Abiraterone) Approval Criteria [Castration-Resistant Prostate Cancer (CRPC) Diagnosis]:

• Diagnosis of metastatic CRPC; and
• Abiraterone must be used in combination with a corticosteroid; and
• Concomitant treatment with a gonadotropin-releasing hormone (GnRH) analog or prior history of bilateral orchiectomy; and
• Use of the 500mg tablet will require a patient-specific, clinically significant reason why the member cannot use generic abiraterone 250mg tablets.

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; and
• Use of the 500mg tablet will require a patient-specific, clinically significant reason why the member cannot use generic abiraterone 250mg tablets.

Prior Authorization Form - Zytiga