trifluridine and tipiracil — CareFirst (Caremark)

Initial criteria

• For colorectal cancer: member has advanced or metastatic colorectal cancer (including appendiceal adenocarcinoma and anal adenocarcinoma) and will use as a single agent or in combination with bevacizumab
• Member has progressed on previous treatment with all of the following regimens unless contraindicated or intolerant: fluoropyrimidine-, oxaliplatin- and irinotecan-based chemotherapy (with or without bevacizumab)
• If RAS mutation status is negative (wild-type), member has been treated with an anti-epidermal growth factor receptor (EGFR) therapy such as cetuximab or panitumumab for rectal cancer, appendiceal adenocarcinoma, anal adenocarcinoma, or left-sided colon cancer
• For esophagogastric junction/gastric/gastroesophageal junction adenocarcinoma: member has been previously treated with at least two prior lines of chemotherapy that included fluoropyrimidine, a platinum, either a taxane or irinotecan, and if appropriate, HER2/neu-targeted therapy
• Disease is unresectable locally advanced, recurrent, or metastatic OR member is not a candidate for surgery

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on the current regimen

Approval duration

12 months