Lorbrena (lorlatinib)
Indications for Prior Authorization
Lorbrena (lorlatinib)
-
For diagnosis of Non-small cell lung cancer (NSCLC)
Indicated for the treatment of adult patients with metastatic non-small cell lung cancer (NSCLC) whose tumors are anaplastic lymphoma kinase (ALK)-positive as detected by an FDA-approved test.
Criteria
Lorbrena
Prior Authorization (Initial Authorization)
Length of Approval: 12 Month(s)
- Diagnosis of non-small cell lung cancer (NSCLC) AND
- One of the following:
- Patient has had disease progression on, contraindication or intolerance to, or is not a candidate for one of the following:
- Alecensa (alectinib)
- Alunbrig (brugatinib)
- For continuation of prior therapy
Lorbrena
Prior Authorization (Reauthorization)
Length of Approval: 12 Month(s)
- Patient does not show evidence of progressive disease while on therapy
P & T Revisions
2025-02-27, 2024-01-23, 2023-07-05, 2023-06-03, 2023-01-04, 2021-12-14, 2021-04-14, 2020-12-07, 2019-12-03
References
- Lorbrena Prescribing Information. Pfizer Labs. New York, NY. August 2024.
Revision History
- 2025-02-27: 2025 Annual Review - No criteria changes
- 2024-01-23: 2024 Annual Review - No changes to criteria
- 2023-07-05: update guideline
- 2023-06-03: Program update to remove criterion that confirms ALK tumor status.
- 2023-01-04: 2023 Annual Review: no changes to clinical criteria
- 2021-12-14: 2022 Annual Review: no changes to clinical criteria
- 2021-04-14: Modified PA per new FDA approved indication. Added embedded ST. Updated background and references. Updated GPIs due to GPI replication.
- 2020-12-07: 2021 Annual Review: updated reauth criteria
- 2019-12-03: 2020 Annual Review; no changes
HEALTHY LIVING