Pharmacy Prior Authorization Criteria

Temodar (temozolomide)

For diagnosis of Newly Diagnosed Glioblastoma
Indicated for the treatment of adult patients with newly diagnosed glioblastoma concomitantly with radiotherapy and then as maintenance treatment.
For diagnosis of Anaplastic Astrocytoma
Indicated for the adjuvant treatment of adults with newly diagnosed anaplastic astrocytoma and treatment of adults with refractory anaplastic astrocytoma.

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Glioblastoma, Anaplastic Astrocytoma

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Glioblastoma, Anaplastic Astrocytoma

2024-07-31, 2023-11-01, 2023-07-21, 2023-05-04, 2022-07-06, 2021-07-06, 2021-05-26, 2021-05-25, 2020-07-01, 2019-08-29

Temodar Prescribing Information, Merck & Co, Inc. Whitehouse Station, NJ. September 2023.
National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Central Nervous System Cancers v.2.2022. Available by subscription at: https://www.nccn.org/professionals/physician_gls/pdf/bone.pdf. Accessed on July 6, 2022.

2024-07-31: Annual review: No criteria changes.
2023-11-01: Update to Indications. Updated references.
2023-07-21: Annual Review: Removal of specialist requirement.
2023-05-04: Program update to remove criterion related to concomitant use or previous therapeutic use
2022-07-06: Annual review: No criteria changes. Updated references.
2021-07-06: annual review: updated indication verbiage to match PI and subsequently updated any indication verbiage changes in criteria section to align with the PI, updated references - no changes to clinical intent
2021-05-26: Addition of EHB formulary to guideline, no changes to criteria
2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
2020-07-01: 2020 Annual Review; no clinical changes
2019-08-29: 2019 annual review - no clinical criteria changes.