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lorlatinib — CareFirst (Caremark)

ALK rearrangement-positive recurrent, advanced, or metastatic non-small cell lung cancer (NSCLC) including brain metastases

Initial criteria

  • Diagnosis of recurrent, advanced, or metastatic NSCLC
  • Tumor is ALK rearrangement-positive as detected by an FDA-approved test
  • Used as a single agent

Reauthorization criteria

  • No evidence of unacceptable toxicity while on the current regimen

Approval duration

12 months