Iressa — CareFirst (Caremark)
Non-small cell lung cancer (NSCLC)
Initial criteria
- Documentation of EGFR mutation testing results
- Member has recurrent, advanced, or metastatic NSCLC
- Disease is EGFR sensitizing mutation-positive
- Used as a single agent
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