Alecensa (alectinib) — CareFirst (Caremark)

Initial criteria

• Authorization may be granted for treatment of ALK-rearrangement positive pediatric diffuse high-grade glioma when either of the following criteria are met:
• — The disease is recurrent or progressive and the member does not have IDH-mutant and 1p/19q codeleted oligodendroglioma or IDH-mutant astrocytoma.
• — The request is for adjuvant treatment and the member does not have disease that is diffuse midline, H3 K27-altered or pontine location.

Reauthorization criteria

• Authorization may be granted for continued treatment when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.

Approval duration

12 months