Skip to content
The Policy VaultThe Policy Vault

Xalkori (crizotinib) — CareFirst (Caremark)

Histiocytic Neoplasms (Erdheim-Chester Disease, Rosai-Dorfman Disease, Langerhans Cell Histiocytosis)

Initial criteria

  • Treatment as a single agent in members with an ALK gene fusion and symptomatic or relapsed/refractory disease (Erdheim-Chester Disease, Rosai-Dorfman Disease, or Langerhans Cell Histiocytosis)

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