Lonsurf (trifluridine-tipiracil) — Highmark

Initial criteria

• age ≥ 18 years
• diagnosis of metastatic gastric cancer (ICD-10: C16) OR metastatic gastroesophageal junction adenocarcinoma (ICD-10: C15.5)
• previously treated with at least two of the following: fluoropyrimidine-containing chemotherapy, platinum-containing chemotherapy, taxane-containing chemotherapy or irinotecan-containing chemotherapy, HER2/neu-targeted 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