Xalkori (crizotinib) — United Healthcare
Non-Small Cell Lung Cancer (NSCLC)
Preferred products
- Alecensa (alectinib)
- Alunbrig (brigatinib)
- Lorbrena (lorlatinib)
Initial criteria
- Diagnosis of non-small cell lung cancer (NSCLC)
- Disease is metastatic OR recurrent OR advanced
- Tumor is ROS1-positive OR positive for mesenchymal-epithelial transition (MET) amplification OR positive for MET exon 14 skipping mutation OR (tumor is ALK-positive AND (provider attests contraindication/intolerance/inappropriateness to Alecensa (alectinib), Alunbrig (brigatinib), and Lorbrena (lorlatinib)) OR (patient currently on Xalkori AND patient has not received manufacturer sample assistance or free trial))
Reauthorization criteria
- Patient does not show evidence of progressive disease while on Xalkori therapy
Approval duration
12 months