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Vitrakvi — Medical Mutual

Solid tumors

Initial criteria

  • The member has a solid tumor that is metastatic OR surgical resection is likely to result in severe morbidity
  • The member does NOT have a known acquired resistance mutation
  • There are no satisfactory alternative treatments OR the patient has progressed following treatment
  • Tumors are neurotrophic receptor tyrosine kinase (NRTK) gene fusion positive, as detected by an FDA-approved diagnostic test
  • The member has fully recovered from toxic effects of prior chemotherapy
  • The member has a Karnofsky score greater than 50% OR an ECOG score of 2 or less
  • Vitrakvi is prescribed by or in consultation with a hematologist or oncologist

Reauthorization criteria

  • A response to therapy is required for continuation of therapy

Approval duration

Initial: 90 days; Reauth: 1 year