Vizimpro — CareFirst (Caremark)
Non-small cell lung cancer (NSCLC), recurrent, advanced or metastatic EGFR-sensitizing mutation-positive
Initial criteria
- Member has recurrent, advanced or metastatic non-small cell lung cancer (NSCLC)
- Disease is EGFR-sensitizing mutation-positive as detected by an FDA-approved test
- Vizimpro will be 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