everolimus — CareFirst (Caremark)
Histiocytic neoplasm subtypes including Erdheim-Chester Disease (ECD), Rosai-Dorfman Disease, Langerhans Cell Histiocytosis (LCH)
Initial criteria
- Member has a phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) mutation AND disease is symptomatic or relapsed/refractory
Reauthorization criteria
- Continuation may be approved when no unacceptable toxicity or disease progression
Approval duration
12 months