Pharmacy Prior Authorization Criteria

Cosela (trilaciclib) - PA, NF

Indications for Prior Authorization

Cosela (trilaciclib)

• For diagnosis of Chemotherapy-induced myelosuppression
  Indicated to decrease the incidence of chemotherapy-induced myelosuppression in adult patients when administered prior to a platinum/etoposide-containing regimen or topotecan-containing regimen for extensive-stage small cell lung cancer (ES-SCLC).

Criteria

Cosela

Prior Authorization

Length of Approval: 6 Month(s)

• Diagnosis of extensive-stage small cell lung cancer (ES-SCLC)
AND
• Patient is receiving one of the following anti-cancer chemotherapeutic regimens:
• Platinum/etoposide-containing regimen
• Topotecan-containing regimen
AND
• Infusion is completed within 4 hours prior to the start of chemotherapy
AND
• The interval between doses on sequential days will not be greater than 28 hours

Cosela

Non Formulary

Length of Approval: 6 Month(s)

• Diagnosis of extensive-stage small cell lung cancer (ES-SCLC)
AND
• Patient is receiving one of the following anti-cancer chemotherapeutic regimens:
• Platinum/etoposide-containing regimen
• Topotecan-containing regimen
AND
• Infusion is completed within 4 hours prior to the start of chemotherapy
AND
• The interval between doses on sequential days will not be greater than 28 hours

P & T Revisions

2024-01-31, 2023-07-25, 2022-01-04, 2021-04-09

References

1. Cosela Prescribing Information. G1 Therapeutics, Inc. Durham, NC. August 2023.

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Revision History

• 2024-01-31: Annual review - no criteria changes; background updates
• 2023-07-25: Removed specialist request
• 2022-01-04: Addition of NF criteria section
• 2021-04-09: New program

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