Vizimpro — United Healthcare
Non-small cell lung cancer (NSCLC)
Initial criteria
- Diagnosis of NSCLC
- Disease is recurrent, advanced or metastatic
- Disease is positive for one of the following EGFR mutations: Exon 19 deletion OR Exon 21 L858R substitution OR S768I OR L861Q OR G719X
Reauthorization criteria
- Patient does not show evidence of progressive disease while on Vizimpro therapy
Approval duration
12 months