Pharmacy Prior Authorization Criteria

Tevimbra (tislelizumab)

Indications for Prior Authorization

Tevimbra (tislelizumab)

• For diagnosis of Esophageal Squamous Cell Carcinoma
  Indicated for the treatment of adult patients with unresectable or metastatic esophageal squamous cell carcinoma after prior systemic chemotherapy that did not include a PD-(L)1 inhibitor

Criteria

Tevimbra

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of esophageal squamous cell carcinoma
AND
• Disease is one of the following:
• Unresectable
• Metastatic
AND
• Patient has received prior systemic chemotherapy
AND
• Patient has not previously been treated with a PD-(L)1 inhibitor (e.g., Keytruda, Opdivo)

Tevimbra

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2024-09-26, 2024-09-27

References

1. Tevimbra Prescribing Information. BeiGene USA, Inc. San Mateo, CA. March 2024.

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Revision History

• 2024-09-26: New Program for Tevimbra
• 2024-09-27: New Program for Tevimbra

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