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Xalkori (crizotinib) — Highmark

metastatic NSCLC

Initial criteria

  • NSCLC: age ≥ 18 years AND metastatic NSCLC (ICD-10: C34) AND disease is ALK-positive or ROS1-positive as detected by an FDA-approved test AND if oral pellets requested, member has inability to swallow oral capsules
  • ALCL: age 1–21 years AND relapsed or refractory systemic ALCL (ICD-10: C84.6) AND disease is ALK-positive AND if oral pellets requested, body surface area < 1.34 m2 OR inability to swallow oral capsules
  • IMT: age ≥ 1 year AND unresectable, recurrent, or refractory IMT (ICD-10: D48.7) AND disease is ALK-positive AND if oral pellets requested, body surface area < 1.34 m2 OR inability to swallow oral capsules

Reauthorization criteria

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

Approval duration

12 months