ALECENSA (alectinib)

ALECENSA (alectinib)

Self-Administration – Oral

Indications for Prior Authorization:

• Non-small cell lung cancer (NSCLC): Indicated for the treatment of patients with anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer (NSCLC) as detected by an FDA-approved test.

Coverage Criteria:

For diagnosis of non-small cell lung cancer (NSCLC):

• Dose does not exceed 1,200 mg per day, AND

• Prescribed by or in consultation with an oncologist, AND

• The patient has metastatic non-small cell lung cancer, AND

• The patient has anaplastic lymphoma kinase (ALK)-positive disease as detected with an FDA-approved test or test performed at a Clinical Laboratory Improvement Amendments (CLIA)-approved facility*

Reauthorization Criteria:

• Patient has not experienced disease progression

Coverage Duration: 

• Initial: 12 months

• Reauthorization: 12 months

Authorization is not covered for the following:

• The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 

• CLIA-certified laboratories: https://wwwn.cdc.gov/clia/Resources/LabSearch.aspx

Policy Updates:

• 05/16/2023 – Updated indication and coverage criteria, added reauthorization criteria. 

References:

• Alecensa prescribing information. Genentech. South San Francisco, CA. September 2021.