Pharmacy Prior Authorization Criteria

Tabrecta (capmatinib)

Indications for Prior Authorization

Tabrecta (capmatinib)

• For diagnosis of Non-Small Cell Lung Cancer (NSCLC)
  Indicated for the treatment of adult patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have a mutation that leads to mesenchymal-epithelial transition (MET) exon 14 skipping as detected by an FDA-approved test.

Criteria

Tabrecta

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of non-small cell lung cancer (NSCLC)
AND
• Disease is metastatic
AND
• Presence of mesenchymal-epithelial transition (MET) exon 14 skipping positive tumors as detected with an FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)

Tabrecta

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient does not show evidence of progressive disease while on therapy

P & T Revisions

2024-06-20, 2023-06-29, 2023-06-22, 2022-06-17, 2021-06-22, 2021-06-02, 2021-04-09

References

1. Tabrecta Prescribing Information. Novartis Pharmaceuticals Corporation. East Hanover, NJ. March 2024.

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Revision History

• 2024-06-20: 2024 annual review: removed NF criteria as drug is covered on premium formulary. Updated guideline name to reflect this change.
• 2023-06-29: Removed specialist requirement
• 2023-06-22: Annual review - no criteria changes.
• 2022-06-17: Annual review: Updated GL name to include PA, NF guideline types. Updated NF section to require paid claims or submission of medical records to confirm COT.
• 2021-06-22: Added EHB formulary to guideline.
• 2021-06-02: Annual review: Updated criteria.
• 2021-04-09: Updated GPIs

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