Xalkori (crizotinib) — CareFirst (Caremark)

Initial criteria

• Treatment of ALK-translocation positive IMT as a single agent when the member has uterine sarcoma and the disease is advanced, recurrent, metastatic, or inoperable
• OR treatment of ALK-translocation positive IMT as a single agent when the member has a soft tissue sarcoma (not including uterine sarcoma)

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