Zejula — CareFirst (Caremark)

Initial criteria

• Member is in a complete or partial response to platinum-based chemotherapy
• Member has advanced (stage II-IV) disease AND requested medication will be used as a single agent OR in combination with bevacizumab OR Member has recurrent disease with a deleterious or suspected deleterious germline BRCA mutation AND requested medication will be used as a single agent

Reauthorization criteria

• No evidence of unacceptable toxicity or disease progression while on the current regimen

Approval duration

12 months