Pharmacy Prior Authorization Criteria

Fruzaqla (fruquintinib)

Indications for Prior Authorization

Fruzaqla (fruquintinib)

• For diagnosis of Metastatic colorectal cancer (mCRC)
  Indicated for the treatment of adult patients with metastatic colorectal cancer (mCRC) who have been previously treated with fluoropyrimidine , oxaliplatin, and irinotecan based chemotherapy, an anti VEGF therapy, and, if RAS wild type and medically appropriate, an anti-EGFR therapy

Criteria

Fruzaqla

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Metastatic colorectal cancer (mCRC)

• Diagnosis of metastatic colorectal cancer (mCRC)
AND
• Patient has been previously treated with both of the following:
• Fluoropyrimidine-, oxaliplatin-, irinotecan-based chemotherapy (e.g., FOLFOX, FOLFIRI, FOLFOXIRI)
• Anti-VEGF biological therapy (e.g., Avastin [bevacizumab], Zaltrap [ziv-aflibercept])
AND
• One of the following:
• Patient has RAS mutant tumors
OR
• All of the following:
• Patient has RAS wild-type tumors
AND
• Patient has been previously treated with an anti-EGFR biological therapy (e.g., Vectibix [panitumumab], Erbitux [cetuximab])
AND
• One of the following:
• Trial and failure, contraindication or intolerance to Stivarga [regorafenib]
OR
• For continuation of prior therapy

Fruzaqla

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Metastatic colorectal cancer (mCRC)

• Patient does not show evidence of progressive disease while on therapy

P & T Revisions

2024-05-13, 2024-01-08

References

1. Fruzaqla Prescribing Information. Takeda Pharmaceuticals America, Inc., Lexington, MA. November 2023

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Revision History

• 2024-05-13: Commercial formulary strategy to revise the embedded step to remove Lonsurf as a trial option.
• 2024-01-08: New Program

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