Tepmetko (tepotinib) — CareFirst (Caremark)

Initial criteria

• Documentation of a mutation that leads to mesenchymal-epithelial transition (MET) exon 14 skipping or MET amplification in tumor or plasma specimens must be provided.
• The requested medication will be used as a single agent for recurrent, advanced, or metastatic NSCLC with MET exon 14 skipping positive tumors when the member has not experienced disease progression on therapy with a MET exon 14 skipping mutation-targeted regimen.
• OR the requested medication will be used for metastatic NSCLC with high-level MET amplification.

Reauthorization criteria

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

Approval duration

12 months