Afinitor Disperz — CareFirst (Caremark)
Histiocytic neoplasms (Erdheim-Chester Disease, Rosai-Dorfman Disease, Langerhans Cell Histiocytosis) with PIK3CA mutation
Initial criteria
- Diagnosis of one of the listed histiocytic neoplasm subtypes
- Presence of phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) mutation
- Requested as single agent for symptomatic or relapsed/refractory disease
Reauthorization criteria
- No evidence of unacceptable toxicity or disease progression while on current regimen
Approval duration
12 months