Zelboraf (vemurafenib tablets) — Cigna

Central Nervous System Cancer

Initial criteria

Medication is being used for ONE of the following: adjuvant treatment of pilocytic astrocytoma, pleomorphic xanthoastrocytoma, circumscribed ganglioglioma/neuroglioma/glioneuronal tumor, or pediatric diffuse high-grade glioma; OR recurrent or progressive disease for high-grade glioma, circumscribed glioma, or glioblastoma; OR brain metastases due to melanoma
Patient has BRAF V600 mutation-positive disease
Medication is prescribed in combination with Cotellic (cobimetinib tablets)

1 year