Tepmetko (tepotinib) - PA, NF
Indications for Prior Authorization
Tepmetko (tepotinib)
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For diagnosis of Non-small cell lung cancer (NSCLC)
Indicated for the treatment of adult patients with metastatic non-small cell lung cancer (NSCLC) harboring mesenchymal-epithelial transition (MET) exon 14 skipping alterations.
Criteria
Tepmetko
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 alterations [A] AND
- One of the following:
- Trial and failure, contraindication, or intolerance to Tabrecta OR
- For continuation of prior therapy
Tepmetko
Prior Authorization (Reauthorization)
Length of Approval: 12 Month(s)
- Patient does not show evidence of progressive disease while on therapy AND
- One of the following:
- Trial and failure, contraindication, or intolerance to Tabrecta OR
- For continuation of prior therapy
Tepmetko
Non Formulary
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 alterations [A] AND
- One of the following:
- Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure, contraindication, or intolerance to Tabrecta OR
- Paid claims or submission of medical records (e.g., chart notes) confirming continuation of prior therapy, defined as no more than a 45-day gap in therapy
P & T Revisions
2024-04-18, 2023-07-06, 2023-04-22, 2022-04-21, 2021-11-24, 2021-09-28, 2021-07-07, 2021-04-07
References
- Tepmetko Prescribing Information. EMD Serono, Inc. Rockland, MA. February 2024.
End Notes
- An FDA-approved test for detection of MET exon 14 skipping alterations in NSCLC for selecting patients for treatment with Tepmetko is not available. Testing for the presence of MET exon 14 skipping alterations in plasma specimens is recommended only in patients for whom a tumor biopsy cannot be obtained. [1]
Revision History
- 2024-04-18: 2024 annual review: Added trial and failure requirement of Tabrecta or COT to reauth. Background updates.
- 2023-07-06: Removed specialist requirement
- 2023-04-22: Annual review: no criteria changes.
- 2022-04-21: Annual review: no criteria changes.
- 2021-11-24: Update Non-Formulary Criteria
- 2021-09-28: GPI replication update.
- 2021-07-07: Updated guideline name, guideline type (added Non Formulary), and added formulary strategy.
- 2021-04-07: New Program
HEALTHY LIVING