Pharmacy Prior Authorization Criteria

Imdelltra (tarlatamab-dlle)

Indications for Prior Authorization

Imdelltra (tarlatamab-dlle)

• For diagnosis of Small cell lung cancer (SCLC)
  Indicated for the treatment of adult patients with extensive stage small cell lung cancer (ES-SCLC) with disease progression on or after platinum-based chemotherapy. This indication is approved under accelerated approval based on overall response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).

Criteria

Imdelltra

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of extensive stage small cell lung cancer (ES-SCLC)
AND
• Disease has progressed on or after platinum-based chemotherapy (e.g., cisplatin, carboplatin)
AND
• Patient has an Eastern Cooperative Oncology Group (ECOG) Score of 0 or 1

Imdelltra

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2024-07-02

References

1. Imdelltra Prescribing Information. Amgen Inc. Thousand Oaks, CA. May 2024.

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Revision History

• 2024-07-02: New Program

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