Pharmacy Prior Authorization Criteria

Truseltiq (infigratinib)

Indications for Prior Authorization

Truseltiq (infigratinib)

• For diagnosis of Cholangiocarcinoma
  Indicated for the treatment of adults with previously treated, unresectable locally advanced or metastatic cholangiocarcinoma with a fibroblast growth factor receptor 2 (FGFR2) fusion or other rearrangement as detected by an FDA-approved test.

Criteria

Truseltiq

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of cholangiocarcinoma
AND
• Disease is one of the following:
• Unresectable locally advanced
• Metastatic
AND
• Disease has presence of a fibroblast growth factor receptor 2 (FGFR2) fusion or other rearrangement as detected by an FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Patient has been previously treated

Truseltiq

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2024-05-01, 2023-06-20, 2023-04-06, 2022-05-06, 2021-07-07

References

1. Truseltiq Prescribing Information. QED Therapeutics, Inc. Brisbane, CA. May 2021.

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Revision History

• 2024-05-01: 2024 Annual Review - no changes
• 2023-06-20: Removal of specialist requirement; NOTE - Correction - Per RxClaims, not obsolete until 3/31/2025
• 2023-04-06: 2023 Annual Review - no changes
• 2022-05-06: 2022 Annual Review- no changes
• 2021-07-07: New program

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