Xalkori (crizotinib) — CareFirst (Caremark)
Non-Small Cell Lung Cancer (NSCLC)
Initial criteria
- Member has recurrent, advanced or metastatic ALK-rearrangement positive NSCLC and will be used as a single agent
- OR Member has recurrent, advanced or metastatic ROS1-rearrangement positive NSCLC and will be used as a single agent
- OR Member has recurrent, advanced or metastatic MET exon 14 skipping mutation-positive NSCLC and will be used as a single agent
- OR Member has metastatic NSCLC with high-level MET amplification
Reauthorization criteria
- Authorization may be renewed when there is no evidence of unacceptable toxicity while on the current regimen
Approval duration
12 months