LORBRENA (lorlatinib)

LORBRENA (lorlatinib) 

SELF ADMINISTRATION - ORAL

Diagnosis considered for coverage:

• 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.

Coverage Criteria:

• Dose does not exceed 100 mg per day, AND

• Prescribed by or in consultation with an oncologist, AND

• The patient has a diagnosis of metastatic non-small cell lung cancer (NSCLC), AND

• The patient has an anaplastic lymphoma kinase (ALK)-positive tumor 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), 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), OR

  • For continuation of prior therapy

Reauthorization Criteria:

For all indications:

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

Coverage Duration: 

• Initial: 1 year
• Reauthorization: 1 year

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: 

• Dosing

  • The recommended dosage of LORBRENA is 100 mg orally once daily, with or without food, until disease progression or unacceptable toxicity

• Drug Interactions

  • Strong CYP3A Inhibitors: Avoid concomitant use.

  • Strong CYP3A Inducers: Avoid concomitant use.

  • Avoid concomitant use of LORBRENA with fluconazole

Policy Updates:

• 05/16/2023 – Updated criteria.

References:

• Lorbrena Prescribing Information. Pfizer Labs. New York, NY. March 2021.