Augtyro — Blue Cross Blue Shield of Illinois
metastatic ROS1-positive non-small cell lung cancer (NSCLC)
Preferred products
- Rozlytrek
- Xalkori
Initial criteria
- Patient must meet ALL general initial evaluation criteria
- Requested agent may be approved if patient meets genetic/diagnostic, indication, and therapy use requirements
- Requested agent is non-preferred for specified indication; approval requires ONE of the following: current stable use; failure, intolerance, contraindication, or non-effectiveness of ONE preferred agent (Rozlytrek or Xalkori); NCCN support for requested agent; or medical necessity justification