Pharmacy Prior Authorization Criteria

Loqtorzi (toripalimab-tpzi)

Indications for Prior Authorization

Loqtorzi (toripalimab-tpzi)

• For diagnosis of Nasopharyngeal carcinoma (NPC)
  Indicated, in combination with cisplatin and gemcitabine, for the first-line treatment of adults with metastatic or with recurrent, locally advanced NPC. Indicated, as a single agent, for the treatment of adults with recurrent unresectable or metastatic NPC with disease progression on or after a platinum-containing chemotherapy.

Criteria

Loqtorzi

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Nasopharyngeal carcinoma

• Diagnosis of nasopharyngeal carcinoma (NPC)
AND
• Disease is one of the following:
• metastatic
• recurrent and locally advanced
AND
• One of the following:
• All of the following:
• Loqtorzi is being used as first line NPC treatment
AND
• Loqtorzi is being used in combination with cisplatin and gemcitabine
AND
• Treatment duration of Loqtorzi has not exceeded a total of 24 months during the patient's lifetime
OR
• Both of the following:
• Loqtorzi is being used as recurrent NPC treatment
AND
• Disease has progressed on or after a platinum containing chemotherapy

Loqtorzi

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Nasopharyngeal carcinoma

• All of the following:
• Loqtorzi is being used as first line NPC treatment
AND
• Patient does not show evidence of progressive disease while on therapy
AND
• Treatment duration of Loqtorzi has not exceeded a total of 24 months during the patient's lifetime
OR
• Both of the following:
• Loqtorzi is being used as recurrent NPC treatment
AND
• Patient does not show evidence of progressive disease while on therapy

P & T Revisions

2024-02-07

References

1. Loqtorzi Prescribing Information.Coherus BioSciences, Inc. Redwood City, CA. October 2023

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Revision History

• 2024-02-07: New Program.

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