Pharmacy Prior Authorization Criteria

Oncology Injectable

Indications for Prior Authorization

Criteria

Adcetris, Aliqopa, Arzerra, Bavencio, Beleodaq, Besponsa, Blincyto, Columvi, Cyramza, Danyelza, Elahere, Elrexfio, Elzonris, Empliciti, Enhertu, Epkinly, Erbitux, Eribulin mesylate, Firmagon, Folotyn, Brand Pralatrexate, Halaven, Imfinzi, Imjudo, Istodax, Romidepsin, Jemperli, Kadcyla, Keytruda, Kyprolis, Libtayo, Lumoxiti, Lunsumio, Margenza, Monjuvi, Mylotarg, Opdivo, Padcev, Perjeta, Phesgo, Polivy, Portrazza, Poteligeo, Provenge, Rylaze, Sarclisa, Tecentriq, Tecentriq Hybreza, Tecvayli, Tivdak, Vyloy, Yervoy, Zaltrap, Zepzelca

Administrative

Length of Approval: 12 Month(s)

• One of the following:
• Both of the following:
• Prescribed medication is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Both of the following labeling requirements have been confirmed:
• All components of the FDA approved indication are met (e.g., concomitant use, previous therapy requirements, age limitations, testing requirements, etc.)
AND
• Prescribed medication will be used at a dose which is within FDA recommendations
OR
• Meets the off-label administrative guideline criteria

Abecma, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta

Administrative

Length of Approval: 1 Time Authorization in Lifetime

• One of the following:
• All of the following:
• Prescribed medication is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Both of the following labeling requirements have been confirmed:
• All components of the FDA approved indication are met (e.g., concomitant use, previous therapy requirements, age limitations, testing requirements, etc.)
AND
• Prescribed medication will be used at a dose which is within FDA recommendations
AND
• Patient has not previously received CAR-T Cell Therapy for the requested indication
OR
• Meets the off-label administrative guideline criteria

P & T Revisions

2024-12-20, 2024-12-03, 2024-11-06, 2024-10-02, 2024-08-19, 2024-06-21, 2024-05-03, 2024-04-03, 2024-03-22, 2024-01-26, 2024-01-16, 2023-10-24, 2023-10-02, 2023-08-23, 2023-08-01, 2023-07-11, 2023-06-20, 2023-05-01, 2023-03-02, 2022-12-05, 2022-11-14, 2022-09-08, 2022-02-01, 2021-11-19, 2021-09-16, 2021-05-21, 2021-04-12, 2021-02-19, 2020-07-31, 2020-02-20, 2020-01-29

References

---

Revision History

• 2024-12-20: update guideline
• 2024-12-03: Addition of Vyloy, Imjudo, Tecvayli, Kyprolis to guideline.
• 2024-11-06: Addition of Tecentriq Hybreza and Sarclisa to guideline
• 2024-10-02: Addition of Elrexfio to guideline
• 2024-08-19: Addition of Columvi, Epkinly, Imfinzi, and Mylotarg to guideline.
• 2024-06-21: Addition of Brand and generic Halaven, Enhertu, Libtayo and Zaltrap.
• 2024-05-03: Addition of Bavencio and Besponsa
• 2024-04-03: Added Istodax and Romidepsin to guideline.
• 2024-03-22: 2024 Annual Review.
• 2024-01-26: update guideline
• 2024-01-16: Addition of Elahere to guideline
• 2023-10-24: Addition of Kadcyla and Tivdak to guideline
• 2023-10-02: Program Update
• 2023-08-23: 2023 Annual Review
• 2023-08-01: Addition of Zepzelca
• 2023-07-11: Removed prescriber requirement. Added Car-T cell products, Folotyn and Brand Pralatrexate to guideline.
• 2023-06-20: Addition of Polivy
• 2023-05-01: Program Update
• 2023-03-02: 2023 Annual Review
• 2022-12-05: Removal of Blenrep from guidelines
• 2022-11-14: Addition of Blenrep to guideline.
• 2022-09-08: Addition of Rylaze
• 2022-02-01: 2022 Annual Review
• 2021-11-19: Addition of Erbitux to guideline
• 2021-09-16: Addition of Opdivo 120mg/12ml strength
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2021-04-12: GPI Replication. No change to clinical criteria.
• 2021-02-19: 2021 UM Annual Review.
• 2020-07-31: Added Cyramza to guideline
• 2020-02-20: 2020 UM Annual Review. No changes to criteria.
• 2020-01-29: Added Adcetris, Elzonris, and Lartruvo to guideline.

---