Pharmacy Prior Authorization Criteria

Mektovi (binimetinib)

Indications for Prior Authorization

Mektovi (binimetinib)

• For diagnosis of BRAF V600E or V600K unresectable or metastatic melanoma
  Indicated in combination with Braftovi (encorafenib), for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600E or V600K mutation, as detected by an FDA-approved test.

• For diagnosis of Non-Small Cell Lung Cancer (NSCLC)
  Indicated in combination with Braftovi (encorafenib) for the treatment of adult patients with metastatic non-small cell lung cancer (NSCLC) with a BRAF V600E mutation, as detected by an FDA-approved test.

Criteria

Mektovi

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Melanoma

• One of the following diagnoses:
• Unresectable melanoma
• Metastatic melanoma
AND
• Cancer is BRAF V600E or V600K mutant type as detected by an FDA-approved test (THxID-BRAF Kit) or performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Used in combination with encorafenib
AND
• One of the following:
• Trial and failure, contraindication or intolerance to one of the following:
• Cotellic
• Mekinist
OR
• For continuation of prior therapy

Mektovi

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Non-Small Cell Lung Cancer

• Diagnosis of metastatic non-small cell lung cancer (NSCLC)
AND
• Cancer is BRAF V600E mutant type as detected by an FDA-approved test (THxID-BRAF Kit) or performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Used in combination with encorafenib

Mektovi

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of All indications listed above

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

P & T Revisions

2024-06-05, 2023-11-29, 2023-07-20, 2023-06-19, 2022-05-23, 2021-06-09, 2020-06-02

References

1. Mektovi Prescribing Information. Array Biopharma Inc. Boulder, CO. October 2023.
2. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology: Melanoma: Cutaneous v.2.2024. Available at: https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf. Accessed May 31, 2024.

---

Revision History

• 2024-06-05: 2024 Annual Review. No criteria changes. Updated references.
• 2023-11-29: Addition of new indication for NSCLC. Updated background and references.
• 2023-07-20: update guideline
• 2023-06-19: Annual review
• 2022-05-23: Annual Review
• 2021-06-09: Annual Review
• 2020-06-02: Annual Review

---