Lonsurf (trifluridine-tipiracil) — Highmark

Initial criteria

• age ≥ 18 years
• diagnosis of metastatic colorectal cancer (ICD-10: C19)
• Lonsurf will be used as a single agent or in combination with bevacizumab
• previously treated with all of the following: fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy AND an anti-VEGF therapy AND if RAS wild-type and disease is left-sided, an anti-EGFR therapy

Reauthorization criteria

• prescriber attests the member is tolerating therapy AND has experienced a therapeutic response defined as disease improvement OR delayed disease progression

Approval duration

12 months