Zykadia (ceritinib) — 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)
- AND (Disease is metastatic OR Disease is recurrent OR Disease is advanced)
- AND Tumor is anaplastic lymphoma kinase (ALK)-positive
- AND (Provider attests the patient has a contraindication, history of intolerance, or that the patient is not an appropriate candidate (document reason) to all of the following therapies: Alecensa (alectinib), Alunbrig (brigatinib), Lorbrena (lorlatinib) OR Patient is currently on Zykadia therapy AND Patient has not received a manufacturer supplied sample at no cost, assistance program medication, or 30-day free trial)
Reauthorization criteria
- Patient does not show evidence of progressive disease while on Zykadia therapy
Approval duration
12 months