Pharmacy Prior Authorization Criteria

Vizimpro (dacomitinib)

Indications for Prior Authorization

Vizimpro (dacomitinib)

• For diagnosis of Non Small Cell Lung Cancer (NSCLC)
  Indicated for the first-line treatment of patients with metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 19 deletion or exon 21 L858R substitution mutations as detected by an FDA-approved test.

Criteria

Vizimpro

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of non-small cell lung cancer (NSCLC) [2]
AND
• Disease is metastatic [2]
AND
• Disease is positive for one of the following epidermal growth factor receptor (EGFR) mutations as detected by a U.S. Food and Drug Administration (FDA)-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA): [2]
• Exon 19 deletion
• Exon 21 L858R substitution

Vizimpro

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2024-09-04, 2023-09-11, 2023-06-26, 2022-09-30, 2021-09-09, 2021-04-09, 2020-10-08, 2019-09-16

References

1. Vizimpro prescribing information. Pfizer Labs. New York, NY. December 2020.
2. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Non-small cell lung cancer v.4.2022. Available by subscription at: https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Accessed September 11, 2022.

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Revision History

• 2024-09-04: 2024 Annual Review
• 2023-09-11: 2023 Annual Review
• 2023-06-26: Removed specialist requirement
• 2022-09-30: 2022 Annual Review
• 2021-09-09: 2021 Annual Review.
• 2021-04-09: Updated GPIs
• 2020-10-08: 2020 Annual Review: updated reauthorization criteria
• 2019-09-16: 2019 Annual Review. No clinical criteria changes.

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