Alecensa (alectinib) — CareFirst (Caremark)

Initial criteria

• Authorization may be granted for treatment of recurrent, advanced or metastatic ALK-positive NSCLC (including brain metastases from NSCLC) as a single agent.
• Authorization may be granted for the adjuvant treatment of ALK-positive NSCLC (tumors ≥ 4 cm or node positive) following complete tumor resection as a single agent.
• Submission of ALK mutation status is required.

Reauthorization criteria

• Authorization may be granted for continued treatment when there is no evidence of unacceptable toxicity while on the current regimen for recurrent, advanced, or metastatic NSCLC.
• Authorization may be granted for continued adjuvant treatment (up to a maximum of 2 years) when there is no evidence of unacceptable toxicity or disease recurrence.

Approval duration

12 months (up to 2 years for adjuvant reauthorization)