Skip to content
The Policy VaultThe Policy Vault

Vizimpro (dacomitinib) — Highmark

metastatic non-small cell lung cancer (NSCLC)

Initial criteria

  • Age ≥ 18 years
  • Diagnosis of metastatic NSCLC AND either EGFR exon 19 deletion OR EGFR exon 21 L858R substitution mutation

Reauthorization criteria

  • Prescriber attests member is tolerating therapy AND has experienced disease improvement OR delayed disease progression

Approval duration

12 months