Xalkori (crizotinib) — CareFirst (Caremark)

Initial criteria

• Subsequent treatment of unresectable or metastatic cutaneous melanoma when all of the following are met:
• • The disease is ROS1 gene fusion-positive
• • The member had disease progression, an intolerance, or has a projected risk of progression with BRAF-targeted therapy (e.g., dabrafenib, encorafenib)
• • The medication will be used as a single agent

Reauthorization criteria

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

Approval duration

12 months