Tarceva (erlotinib) — Highmark

Preferred products

• erlotinib (generic)

Initial criteria

• Diagnosis of pancreatic cancer (ICD-10 C25) AND disease classified as locally advanced, unresectable OR metastatic
• Used as first-line therapy
• Used in combination with gemcitabine
• If request is for brand Tarceva, member has experienced therapeutic failure or intolerance to generic erlotinib

Reauthorization criteria

• Prescriber attests member is tolerating therapy AND has experienced disease improvement OR delayed disease progression
• If request is for brand Tarceva, documentation that generic erlotinib is ineffective or not tolerated

Approval duration

12 months