erlotinib — CareFirst (Caremark)
Non-small cell lung cancer (NSCLC)
Initial criteria
- Member has recurrent, advanced, or metastatic NSCLC (including brain metastases from NSCLC)
- Disease is EGFR-sensitizing mutation-positive
- Used as a single agent or in combination with ramucirumab or bevacizumab
Reauthorization criteria
- No evidence of unacceptable toxicity or disease progression while on the current regimen
- OR disease is T790M negative and there is no evidence of unacceptable toxicity
Approval duration
12 months