Gleostine for Brain Tumor

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has received surgical and/or radiotherapeutic procedures, as appropriate.

Leukeran for Chronic Lymphocytic Leukemia (CLL) or Small Lymphocytic Lymphoma (SLL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of CLL/SLL with at least two therapies.

Leukeran for Follicular Lymphoma (FL) or Marginal Zone Lymphoma (MZL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to rituximab monotherapy.

Zepzelca

• Documentation of the following is required:
  • diagnosis of metastatic small cell lung cancer (SCLC); and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to platinum-based chemotherapy.

Alymsys, Avastin, Mvasi, and Zirabev for cervical cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with one of the following:
    • paclitaxel and cisplatin; or
    • paclitaxel and topotecan.

Alymsys, Avastin, Mvasi, and Zirabev for recurrent glioblastoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Avastin for hepatocellular carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with Tecentriq (atezolizumab); and
  • member has Child-Pugh Class A.

Alymsys, Avastin, Mvasi, and Zirabev for metastatic colorectal cancer 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with fluoropyrimidine-, capecitabine-, oxaliplatin-, or irinotecan-containing therapy.

Alymsys, Avastin, Mvasi, and Zirabev for metastatic renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • if predominant clear cell histology, requested agent will be used in combination with interferon alfa.

Alymsys, Avastin, Mvasi, and Zirabev for non-squamous non-small cell lung cancer (NSCLC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with carboplatin and paclitaxel.

Alymsys, Avastin, Mvasi, and Zirabev for non-squamous NSCLC with EGFR Mutation Positive

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested agent will be used in combination with erlotinib.

Alymsys, Avastin, Mvasi, and Zirabev for adenocarcinoma, large cell, NSCLC NOS with PD-L1 Expression Positive

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested agent will be used in combination with carboplatin, paclitaxel and atezolizumab.

Alymsys, Avastin, Mvasi, and Zirabev for initial therapy of advanced or metastatic adenocarcinoma, large cell, NSCLC NOS (POS 0-2)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • member has a contraindication to to PD-1 or PD-L1 inhibitors; and
  • one of the following:
    • requested agent will be used in combination with carboplatin and pemetrexed; or
    • requested agent will be used in combination with cisplatin and pemetrexed.

Alymsys, Avastin, Mvasi, and Zirabev for maintenance therapy of advanced or metastatic adenocarcinoma, large cell, NSCLC NOS (POS 0-2)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • one of the following:
    • requested agent will be used as monotherapy; or
    • requested agent will be used in combination with atezolizumab; or
    • requested agent will be used in combination with pemetrexed.

Alymsys, Avastin, Mvasi, and Zirabev for ovarian, fallopian, or primary peritoneal cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Avastin for wet age-related macular degeneration, macular edema following retinal vein occlusion, diabetic macular edema, or diabetic retinopathy

• Documentation of the following is required:
  • appropriate diagnosis; and
  • requested dosing is 1.25 mg intravitreally every four or eight weeks or as needed.

Cyramza for gastric or gastro-esophageal junction (GEJ) adenocarcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a fluoropyrimidine- or platinum-containing chemotherapy regimen.

Cyramza for HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has alpha fetoprotein (AFP) ≥ 400 ng/mL; and
  • inadequate response, adverse reaction, or contraindication to sorafenib.

Cyramza for metastatic colorectal cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with FOLFIRI or irinotecan; and
  • inadequate response, adverse reaction, or contraindication to a 5-fluorouracil/leucovorin or capecitabine-based regimen.

Cyramza for NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • requested agent will be used in combination with docetaxel; and
      • inadequate response, adverse reaction, or contraindication to a platinum-containing chemotherapy regimen; or
    • all of the following:
      • requested agent will be used in combination with erlotinib; and
      • cancer displays the EGFR exon 19 deletion or exon 21 L858R mutation; and
      • inadequate response or adverse reaction to one of the following used in combination with Tagrisso (osimertinib), or contraindication to both of the following:
        • Gilotrif (afatinib); or 
        • Iressa (gefitinib).

Zaltrap

• Documentation of the following is required:
  • diagnosis of metastatic colorectal cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with either irinotecan or FOLFIRI; and
  • inadequate response or adverse reaction to one of the following regimens or a contraindication to all of the following regimens: a fluoropyrimidine (capecitabine or fluorouracil), CAPEOX, FOLFOX, oxaliplatin-based therapy; and
  • inadequate response, adverse reaction, or contraindication to a bevacizumab product.

abiraterone 250 mg, 500 mg

• Documentation of the following is required:
  • diagnosis of metastatic high-risk castration-sensitive prostate cancer or metastatic castration-resistant prostate cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with prednisone; and 
  • for the 500 mg tablet, medical necessity for use instead of the 250 mg tablet; and
  • one of the following:
    • requested agent will be used in combination with a gonadotropin-releasing hormone (GnRH) analog; or
    • member had a bilateral orchiectomy.

Erleada for metastatic castration-sensitive prostate cancer (mCSPC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to abiraterone; and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Erleada for non-metastatic castration-resistant prostate cancer (NM-CRPC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to Xtandi (enzalutamide); and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Nubeqa for NM-CRPC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to Xtandi (enzalutamide); and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Nubeqa for metastatic hormone-sensitive prostate cancer (mHSPC) or mCSPC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with docetaxel; and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Nubeqa for M1 mCRPC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • one of the following:
    • if no prior docetaxel or no novel hormone therapy, inadequate response, adverse reaction, or contraindication to all of the following: abiraterone, docetaxel, and enzalutamide; or
    • if prior docetaxel but no prior novel hormone therapy, inadequate response, adverse reaction, or contraindication to both of the following: abiraterone and enzalutamide; or
    • if prior novel hormone therapy but no prior docetaxel, inadequate response, adverse reaction, or contraindication to docetaxel; or
    • if prior docetaxel and prior novel hormone therapy, inadequate response, adverse reaction, or contraindication to cabazitaxel.

Xtandi for mCSPC or metastatic castration-resistant prostate cancer (mCRPC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to abiraterone; and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Xtandi for NM-CRPC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing; and
  • one of the following:
    • requested agent will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Yonsa

• Documentation of the following is required:
  • diagnosis of metastatic castration-resistant prostate cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with methylprednisolone; and
  • one of the following:
    • medication will be used in combination with a GnRH analog; or
    • member had a bilateral orchiectomy.

Jelmyto

• Documentation of the following is required:
  • diagnosis of low-grade upper-tract urothelial cancer; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing.
• For recertification, documentation that the member achieved a complete response three months after initiation is required.

Besponsa

• Documentation of the following is required:
  • diagnosis of ALL; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • Philadelphia chromosome-positive; and
      • inadequate response or adverse reaction to one tyrosine kinase inhibitor for the treatment of ALL; or
    • all of the following:
      • Philadelphia chromosome-negative; and
      • B-cell precursor ALL; and
      • prior therapy for the treatment of ALL with one systemic therapy.

Blenrep

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has received at least four prior chemotherapy regimens or contraindication to the use of recommended chemotherapy regimens; and
  • member’s disease is refractory to at least one proteasome inhibitor or the member has a contraindication to all proteasome inhibitors; and
  • member’s disease is refractory to at least one immunomodulatory agent or the member has a contraindication to all immunomodulatory agents; and
  • member’s disease is refractory to at least one anti-CD38 monoclonal antibody or the member has a contraindication to all anti-CD38 monoclonal antibodies.

Enhertu for locally advanced or metastatic HER2-positive gastric or gastroesophageal junction adenocarcinoma

•  Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to a trastuzumab-based regimen.

Enhertu for unresectable or metastatic HER2-positive breast cancer

•  Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one anti-HER2-based regimen.

Enhertu for unresectable or metastatic HER2-low (IHC 1+ or IHC 2+/ISH-) breast cancer

•  Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one prior chemotherapy regimen.

Enhertu for unresectable or metastatic NSCLC with activating HER2 (ERBB2) mutations

•  Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one prior systemic therapy.

Kadcyla 

• Documentation of the following is required:
  • diagnosis of HER2-positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has recurrent or metastatic breast cancer and an inadequate response or adverse reaction to trastuzumab and a taxane separately or in combination; or
    • member has early breast cancer and residual invasive disease after neoadjuvant taxane and trastuzumab-based treatment.

Mylotarg for newly-diagnosed CD33-positive AML in adults and pediatric members one month and older 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ one month of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • requested agent will be used in combination with cytarabine and daunorubicin or fludarabine; or
    • clinical rationale why combination therapy with cytarabine and daunorubicin or fludarabine is not appropriate.

Mylotarg for relapsed or refractory CD33-positive AML 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ two years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • relapsed or refractory AML; or
    • prior therapy for the treatment of AML with one systemic therapy.

Tivdak for recurrent or metastatic cervical cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • inadequate response, adverse reaction, or contraindication to one line of platinum-based chemotherapy; and
  • if PD-L1 positive, inadequate response, adverse reaction, or contraindication to Keytruda (pembrolizumab) or Opdivo (nivolumab).

Infugem

• Documentation of the following is required:
  • diagnosis of breast cancer, non-small cell lung cancer, ovarian cancer or pancreatic cancer; and
  • prescriber is an oncologist or hematologist; and
  • member is ≥ 18 years of age; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a gemcitabine product available without PA.

nelarabine

• Documentation of the following is required:
  • diagnosis of T-cell acute lymphoblastic leukemia (T-ALL) or T-cell lymphoblastic lymphoma (T-LBL); and
  • prescriber is an oncologist; and
  • appropriate dosing.

Pemfexy

• Documentation of the following is required:
  • diagnosis of malignant pleural mesothelioma or NSCLC; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a pemetrexed product available without PA.

Purixan

• Documentation of the following is required:
  • diagnosis of acute lymphoblastic leukemia (ALL); and
  • one of the following:
    • member is < 13 years of age; or
    • medical necessity for the use of an oral suspension formulation (e.g. swallowing disorder).

SmartPA: Claims for Purixan (mercaptopurine oral suspension) will usually process at the pharmacy without a PA request if the member has a MassHealth history of medical claims for ALL and the member is < 13 years of age. ^†

Jevtana

• Documentation of the following is required:
  • diagnosis of metastatic castration-resistant prostate cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with prednisone; and
  • inadequate response or adverse reaction to one docetaxel-containing regimen.

Kisqali-Femara Co-Pack

• Documentation of the following is required:
  • diagnosis of HR-positive, HER2-negative advanced or metastatic breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Lonsurf

• For metastatic colorectal cancer, documentation of the following is required:
  • diagnosis of metastatic colorectal cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to at least one or contraindication to all of the following regimens: CAPEOX, FOLFOX, FOLFIRI, FOLFOXIRI, irinotecan-based therapy, oxaliplatin-based therapy; and
  • if BRAF/KRAS/NRAS wild-type cancer is present, inadequate response or adverse reaction to one or contraindication to both of the following: Erbitux (cetuximab), Vectibix (panitumumab).
• For metastatic gastric or GEJ adenocarcinoma, documentation of the following is required:
  • diagnosis of metastatic gastric or GEJ adenocarcinoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to two prior lines of chemotherapy that included a fluoropyrimidine, a platinum, either a taxane or irinotecan, and if appropriate, HER2/neu-targeted therapy; or
    • contraindication to chemotherapy and HER2/neu-targeted therapy.

Phesgo 

• Documentation of the following is required:
  • diagnosis of HER2-positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • for early breast cancer, requested agent will be used in combination with chemotherapy; or
    • for metastatic breast cancer, requested agent will be used in combination with docetaxel.

Vyxeos

• Documentation of the following is required:  
  • diagnosis of newly diagnosed therapy-related AML or AML with myelodysplasia-related changes (AML-MRC); and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member is ≥ one year of age; and
  • inadequate response, adverse reaction, or contraindication to use of separate daunorubicin and cytarabine chemotherapy agents.

Asparlas

• Documentation of the following is required:
  • diagnosis of ALL; and
  • member is ≥ one month and < 22 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to Oncaspar (pegaspargase); or
  • clinical rationale for use instead of Oncaspar (pegaspargase).
• For recertification requests that exceed a total treatment duration of 36 weeks, documentation of clinical evidence supporting such an extended duration is required.

Erwinase, Rylaze

• Documentation of the following is required:
  • diagnosis of ALL; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • hypersensitivity to E. coli-derived asparaginase.
• For recertification requests that exceed a total treatment duration of 36 weeks, documentation of clinical evidence supporting such an extended duration is required.

Elzonris

• Documentation of the following is required:
  • diagnosis of blastic plasmacytoid dendritic cell neoplasm (BPDCN); and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • first infusion will take place in an inpatient setting, and subsequent infusions may take place in an outpatient setting with appropriate monitoring.

 Onureg

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • achievement of first complete remission (CR) following intensive induction chemotherapy; or
    • complete remission with incomplete blood count recovery (CRi) following intensive induction chemotherapy; and
  • member is not able to complete intensive curative therapy; and
  • requested quantity is ≤ 14 units/28 days.

fulvestrant

• Documentation of the following is required:
  • diagnosis of HR-positive advanced or metastatic breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member is HER2-positive and one of the following:
      • requested agent will be use as monotherapy; or
      • requested agent will be used in combination with trastuzumab; or
    • member is HER2-negative and one of the following:
      • requested agent will be used as monotherapy; or
      • requested agent will be used in combination with a CDK inhibitor (abemaciclib, palbociclib, or ribociclib); or
      • requested agent will be used in combination with anastrozole or letrozole.

Daurismo

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with low dose cytarabine; and
  • one of the following:
    • member is ≥ 75 years of age; or
    • member is ≥ 60 years of age and one of the following:
      • member is not a candidate for intensive induction chemotherapy; or
      • member has significant comorbidities that preclude the use of intensive induction chemotherapy.

Erivedge and Odomzo

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • member has persistent or recurring basal cell carcinoma following surgery and/or radiation therapy; or
  • member is not a candidate for surgery and/or radiation therapy.

Beleodaq for peripheral T-cell lymphoma (PTCL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all second-line treatment options.

Istodax (romidepsin) and romidepsin for cutaneous T-cell lymphoma (CTCL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist, hematologist, or dermatologist; and
  • appropriate dosing.

Istodax (romidepsin) and romidepsin for PTCL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all second-line treatment options.

Pomalyst for multiple myeloma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to both of the following: lenalidomide, Thalomid (thalidomide); and
  • inadequate response or adverse reaction to one or contraindication to all proteasome inhibitors:
    • bortezomib; or
    • Kyprolis (carfilzomib); or
    • Ninlaro (ixazomib); or
    • Velcade (bortezomib).

Pomalyst for Kaposi sarcoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has acquired immunodeficiency syndrome (AIDS) and has failed highly active antiretroviral therapy; or
    • member is human immunodeficiency virus (HIV)-negative; and
  • inadequate response, adverse reaction, or contraindication to both of the following: pegylated liposomal doxorubicin, paclitaxel.

lenalidomide 

• Documentation of the following is required for FL, MZL, myelodysplastic syndrome, or mantle cell lymphoma (MCL):
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • for the 2.5 mg, 5 mg, or 10 mg strength, requested quantity is ≤ one unit/day; or
    • for the 15 mg, 20 mg, or 25 mg strength, requested quantity is ≤ 21 capsules for a 28 day supply; and
  • for previously untreated MZL, documentation of clinical rationale for use instead of one of the following:
    • bendamustine + rituximab; or
    • rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP); or
    • rituximab, cyclophosphamide, vincristine, and prednisone (RCVP); or
    • rituximab; or
  • for treatment of FL or MZL, documentation that the requested agent will be used in combination with rituximab. 

• Documentation of the following is required for multiple myeloma:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • for the 2.5 mg, 5 mg, or 10 mg strength, requested quantity is ≤ one unit/day; or
    • for the 15 mg strength, one of the following:
      • requested quantity is ≤ 21 capsules/28 day supply; or 
      • requested quantity is ≤ one unit/day and inadequate response to 10 mg daily; or
    • for the 20 mg or 25 mg strength, requested quantity is ≤ 21 capsules/28 day supply.

SmartPA: Claims within quantity limits for lenalidomide will usually process at the pharmacy without a PA request if the member has a MassHealth history of medical claims for multiple myeloma. ^†

Besremi

• Documentation of the following is required:
  • diagnosis of polycythemia vera; and
  • prescriber is a hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindiation to both of the following: hydroxyurea, Pegasys (peginterferon alfa-2a).

Lumakras for advanced or metastatic non-small cell lung cancer 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has KRAS G12C mutation; and
  • inadequate response or adverse reaction to at least one prior systemic therapy or contraindication to the use of systemic therapy; and
  • requested quantity is ≤ eight units/day.

Aliqopa

• Documentation of the following is required:
  • diagnosis of FL; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of FL with at least two systemic therapies.

Balversa

• Documentation of the following is required:
  • diagnosis of FGFR3- or FGFR2-mutated locally advanced or metastatic urothelial carcinoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has received prior treatment with platinum-containing chemotherapy or is not a candidate for platinum-containing chemotherapy.

Braftovi for unresectable or metastatic melanoma

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF V600E or V600K mutation; and
  • requested agent will be used in combination with Mektovi (binimetinib).

Braftovi for metastatic colorectal cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Erbitux (cetuximab) or Vectibix (panitumumab); and
  • inadequate response or adverse reaction to one or a contraindication to all of the following regimens: CAPEOX, FOLFOX, irinotecan-based therapy, oxaliplatin-based therapy.

Copiktra for CLL or SLL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of CLL/SLL with at least two prior therapies.

Cosela

• Documentation of the following is required:
  • diagnosis of extensive-stage small cell lung cancer (ES-SCLC); and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • requested agent will be used in combination with a platinum/etoposide-containing or topotecan-containing regimen.

Cotellic for low-grade or high-grade gliomas

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested dosing is ≤ 60 mg/day; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Zelboraf (vemurafenib) ≤ 960 mg every 12 hours.

Cotellic for unresectable or metastatic melanoma

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested quantity is ≤ three units/day; and
  • positive BRAF V600E or V600K mutation; and
  • requested agent will be used in combination with Zelboraf (vemurafenib).

Exkivity for advanced or metastatic NSCLC 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has EGFR exon 20 insertion mutation; and
  • inadequate response or adverse reaction to at least one platinum-based chemotherapy regimen or contraindication to the use of platinum-based chemotherapy; and
  • requested quantity is ≤ four units/day.

Gavreto and Retevmo for medullary thyroid cancer or thyroid cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 12 years of age; and
  • requested quantity is ≤ four units/day; and
  • one of the following:
    • member has thyroid cancer and one of the following: member refractory to radioactive iodine or radioactive iodine treatment is not appropriate; or
    • member has medullary thyroid cancer.

Gavreto and Retevmo for NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • requested quantity is ≤ four units/day.

Gilotrif

• Documentation of the following is required:
  • diagnosis of metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has epidermal growth factor receptor (EGFR) mutations; or
    • inadequate response or adverse reaction to at least one platinum-based chemotherapy regimen, or contraindication to the use of platinum-based chemotherapy; and
  • requested quantity is ≤ one unit/day.

Ibrance for HER2-negative, HR-positive breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • the requested agent will be used in combination with an aromatase inhibitor; or
    • the requested agent will be used in combination with fulvestrant; and
  • requested quantity is ≤ one unit/day.

Inrebic

• Documentation of the following is required:
  • diagnosis of one of the following: 
    • intermediate or high-risk primary myelofibrosis (PMF); or
    • post-polycythemia vera myelofibrosis (post-PV MF); or
    • post-essential thrombocythemia myelofibrosis (post-ET MF); and
  • member is ≥ 18 years of age; and
  • inadequate response, adverse reaction, or contraindication to Jakafi (ruxolitinib tablet); and
  • requested quantity is ≤ four units/day.

Jakafi for acute graft versus host disease (aGVHD) or chronic graft versus host disease (cGVHD)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 12 years of age; and
  • inadequate response, adverse reaction, or contraindication to systemic glucocorticoids; and
  • requested quantity is ≤ two units/day.

Jakafi for polycythemia vera (PV)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one of the following, or contraindication to both of the following: hydroxyurea, Pegasys (peginterferon alfa-2a); and
  • requested quantity is ≤ two units/day.

Jakafi for intermediate or high-risk PMF, post-PV MF, or post-ET MF

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • requested quantity is ≤ two units/day.

Kisqali

• Documentation of the following is required:
  • diagnosis of HR-positive, HER2-negative advanced or metastatic breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • requested agent will be used in combination with an aromatase inhibitor; or
    • requested agent will be used in combination with fulvestrant.

Koselugo for plexiform neurofibromas (PN) with neurofibromatosis type 1 (NF1)

• Documentation of the following is required for members ≥ two years of age and < 18 years of age at the start of therapy:
  • appropriate diagnosis; and
  • prescriber is a neurologist or oncologist; and
  • appropriate dosing; and
  • member is ≥ two years of age and < 18 years of age at the start of therapy; and
  • member has at least one measurable PN and complete resection of PN is not feasible without substanstial risk or morbidity.
• Documentation of the following is required for members ≥ 18 years of age:
  • appropriate diagnosis; and
  • prescriber is a neurologist or oncologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • member has at least one measurable PN and complete resection of PN is not feasible without substanstial risk or morbidity.

Lorbrena

• Documentation of the following is required:
  • diagnosis of metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is ALK-positive; and
  • inadequate response, adverse reaction, or contraindication to Alecensa; and
  • requested quantity is ≤ one unit/day.

Mekinist for locally advanced or metastatic anaplastic thyroid cancer

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • one of the following:
    • for 0.5 mg tablets, requested quantity is ≤ three units/day; or
    • for 2 mg tablets, requested quantity is ≤ one unit/day; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Tafinlar (dabrafenib); and
  • member has no satisfactory locoregional treatment options.

Mekinist for low-grade or high-grade gliomas

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested dosing is ≤ 2 mg/day; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Tafinlar (dabrafenib) ≤ 150 mg every 12 hours.

Mekinist for adjuvant treatment of melanoma 

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • one of the following:
    • for 0.5 mg tablets, requested quantity is ≤ three units/day; or
    • for 2 mg tablets, requested quantity is ≤ one unit/day; and
  • positive BRAF V600E or V600K mutation; and
  • requested agent will be used in combination with Tafinlar (dabrafenib); and
  • involvement of lymph nodes following complete resection.

Mekinist for unresectable or metastatic melanoma 

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • one of the following:
    • for 0.5 mg tablets, requested quantity is ≤ three units/day; or
    • for 2 mg tablets, requested quantity is ≤ one unit/day; and
  • positive BRAF V600E or V600K mutation; and
  • one of the following:
    • requested agent will be used in combination with Tafinlar (dabrafenib); or
    • all of the following:
      • requested agent will be used as a single agent; and
      • no history of prior therapy with a BRAF inhibitor (i.e., Tafinlar [dabrafenib] or Zelboraf [vemurafenib]); and
      • clinical rationale for bypassing use of a BRAF inhibitor (i.e., Tafinlar [dabrafenib] or Zelboraf [vemurafenib]).

Mekinist for metastatic NSCLC

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • one of the following:
    • for 0.5 mg tablets, requested quantity is ≤ three units/day; or
    • for 2 mg tablets, requested quantity is ≤ one unit/day; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Tafinlar (dabrafenib).

Mekinist for low-grade serous carcinoma of the ovary, fallopian tube, or primary peritoneum

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested dosing is ≤ 2 mg/day; and
  • medical records documenting an inadequate response, adverse reaction, or contraindication to one platinum-containing regimen and one hormonal therapy.

Mekinist for unresectable or metastatic solid tumors

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • member is ≥ six years of age; and
  • one of the following:
    • for 0.5 mg tablets, requested quantity is ≤ three units/day; or 
    • for 2 mg tablets, requested quantity is ≤ one unit/day; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Tafinlar (dabrafenib).

Mektovi for unresectable or metastatic melanoma

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested quantity is ≤ six units/day; and
  • positive BRAF V600E or V600K mutation; and
  • requested agent will be used in combination with Braftovi (encorafenib).

Mektovi for low-grade serous carcinoma of the ovary, fallopian tube, or primary peritoneum

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested dosing is ≤ 45 mg twice daily; and
  • medical records documenting an inadequate response, adverse reaction, or contraindication to one platinum-containing regimen and one hormonal therapy.

Nerlynx for adjuvant therapy for early stage breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member received trastuzumab therapy within the past two years; and
  • requested quantity is ≤ six units/day.

Nerlynx for treatment of advanced or metastatic breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to two anti-HER2-based regimens; and
  • requested agent will be used in combination with capecitabine; and
  • requested quantity is ≤ six units/day.

Pemazyre for myeloid/lymphoid neoplasms (MLNs) with FGFR1 rearrangement

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age.

Pemazyre and Truseltiq for unresectable locally advanced or metastatic cholangiocarcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor has FGFR2 fusion or other rearrangement; and
  • member is ≥ 18 years of age; and
  • member has received at least one prior treatment; and
  • for Truseltiq, requested quantity is ≤ one blister pack/28 days.

Piqray 

• Documentation of the following is required:
  • diagnosis of HR-positive, HER2-negative, PIK3CA-mutated breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • disease has progressed following treatment with endocrine-based therapy; and
  • requested agent will be used in combination with fulvestrant.

Qinlock

• Documentation of the following is required:
  • diagnosis of gastrointestinal stromal tumor (GIST); and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to at least three prior kinase inhibitor therapies, one of which is imatinib; and
  • requested quantity is ≤ three units/day.

Retevmo for locally advanced or metastatic solid tumor

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • cancer is RET fusion-positive; and 
  • requested quantity is ≤ four units/day; and
  • one of the following:
    • inadequate response or adverse reaction to at least one prior systemic therapy, or contraindication to the use of systemic therapy; or
    • member has no satisfactory alternative treatment options.

Rezurock

• Documentation of the following is required:
  • diagnosis of cGVHD; and
  • member is ≥ 12 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to systemic glucocorticoids; and
  • prior therapy for the treatment of cGVHD with at least one prior line of non-steroid systemic therapy; and
  • requested quantity is ≤ one unit/day.

Stivarga for GIST

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to both of the following: imatinib and sunitinib.

Stivarga for HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has Child-Pugh Class A; and
  • inadequate response, adverse reaction, or contraindication to sorafenib.

Stivarga for metastatic colorectal cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all of the following regimens: CAPEOX, FOLFIRI, FOLFOX, FOLFOXIRI, irinotecan-based therapy, oxaliplatin-based therapy; and
  • if BRAF/KRAS/NRAS wild-type cancer is present, inadequate response or adverse reaction to one of the following, or a contraindication to both of the following: Erbitux (cetuximab), Vectibix (panitumumab).

Stivarga for osteosarcoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to both of the following regimens: cisplatin and doxorubicin, high-dose methotrexate, cisplatin, and doxorubicin.

Tabrecta for MET exon 14 skipping metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has mutation that leads to MET exon 14 skipping; and
  • requested quantity is ≤ four units/day.

Tabrecta for MET positive amplification metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • cancer is MET positive amplification; and
  • requested quantity is ≤ four units/day.

Tafinlar for locally advanced or metastatic anaplastic thyroid cancer

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested quantity is ≤ four units/day; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Mekinist (trametinib); and
  • member has no satisfactory locoregional treatment options.

Tafinlar for low-grade or high-grade gliomas

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested dosing is ≤ 150 mg every 12 hours; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Mekinist (trametinib) ≤ 2 mg/day.

Tafinlar for adjuvant treatment of melanoma 

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested quantity is ≤ four units/day; and
  • positive BRAF V600E or V600K mutation; and
  • requested agent will be used in combination with Mekinist (trametinib); and
  • involvement of lymph nodes following complete resection.

Tafinlar for unresectable or metastatic melanoma

•  Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested quantity is ≤ four units/day; and
  • if the request is positive BRAF V600K, requested agent will be used in combination with Mekinist (trametinib); and
  • if the request is positive BRAF V600E, one of the following:
    • requested agent will be used in combination with Mekinist (trametinib); or
    • requested agent will be used as monotherapy.

Tafinlar for metastatic NSCLC

•  Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested quantity is ≤ four units/day; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Mekinist (trametinib).

Tafinlar for unresectable or metastatic solid tumors

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • member is ≥ six years of age; and
  • requested quantity is ≤ four units/day; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Mekinist (trametinib).

Tagrisso for advanced or metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested quantity is ≤ one unit/day; and
  • one of the following:
    • cancer displays the EGFR exon 19 deletion or exon 21 L858R mutation; or
    • both of the following:
      • cancer displays the EGFR mutation and the T790M resistance mutation; and
      • inadequate response or adverse reaction to one of the following or contraindication to all of the following: erlotinib, Gilotrif (afatinib), Iressa (gefitinib), Vizimpro (dacomitinib).

Tagrisso for adjuvant treatment for stage IB to IIIA NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested quantity is ≤ one unit/day; and
  • cancer displays the EGFR exon 19 deletion or exon 21 L858R mutation; and
  • member has completely resected disease; and
  • inadequate response or adverse reaction to at least one platinum-based chemotherapy regimen or contraindication to the use of platinum-based chemotherapy.

Tepmetko for MET exon 14 skipping metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer harbors MET exon 14 skipping alterations; and
  • requested quantity is ≤ two units/day.

Tepmetko for MET positive amplification metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • cancer is MET positive amplification; and
  • requested quantity is ≤ two units/day.

Verzenio for HR-positive, HER2-negative early breast cancer (EBC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • the requested agent will be used in combination with an aromatase inhibitor; or
    • the requested agent will be used in combination with tamoxifen; and
  • requested quantity is ≤ two units/day.

Verzenio for HR-positive, HER2-negative advanced or metastatic breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • the requested agent will be used in combination with an aromatase inhibitor; or
    • the requested agent will be used in combination with fulvestrant; or
    • the requested agent will be used as monotherapy when disease has progressed after both hormonal therapy and chemotherapy; and
  • requested quantity is ≤ two units/day.

Vizimpro

• Documentation of the following is required:
  • diagnosis of metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has EGFR mutations; and
  • requested quantity is ≤ one unit/day.

Vonjo

• Documentation of the following is required:
  • diagnosis of one of the following:
    • intermediate or high-risk PMF; or
    • post-PV MF; or
    • post-ET MF; and
  • member is ≥ 18 years of age; and
  • platelet count is ≤ 50 x 10⁹/L; and
  • requested quantity is ≤ four units/day.

Zydelig

• Documentation of the following is required:  
  • diagnosis of CLL; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • relapsed or refractory CLL; or
    • prior therapy for the treatment of CLL with at least one systemic therapy; and
  • inadequate response, adverse reaction, or contraindication to Imbruvica (ibrutinib).

Opdualag

• Documentation of the following is required:
  • diagnosis of unresectable or metastatic melanoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: 
    • Opdivo (nivolumab) in combination with Yervoy (ipilimumab); or
    • Opdivo (nivolumab); or
    • Keytruda (pembrolizumab); and
  • one of the following:
    • member is negative for the BRAF V600E or V600K mutation; or
    • member is positive for the BRAF V600E or V600K mutation and has had an inadequate response or adverse reaction to one or contraindication to all of the following:
      • Tafinlar (dabrafenib) in combination with Mekinist (trametinib); or
      • Zelboraf (vemurafenib) in combination with Cotellic (cobimetinib); or
      • Braftovi (encorafenib) in combination with Mektovi (binimetinib).

Fusilev, Khapzory, and levoleucovorin injection

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ six years of age; and
  • medical records documenting member is not a candidate for leucovorin therapy due to hypersensitivity to a component of leucovorin; and
  • for Khapzory, clinical rationale for use instead of Fusilev (levoleucovorin powder for injection).

Idhifa

• Documentation of the following is required:  
  • diagnosis of IDH2-mutated AML; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested quantity is ≤ one unit/day; and
  • one of the following: 
    • member is ≥ 60 years of age and is not a candidate for intensive remission induction therapy; or
    • relapsed or refractory IDH2-mutated AML; or
    • prior treatment of IDH2-mutated AML with at least one of the following systemic therapies: azacitidine, decitabine, glasdegib, cytarabine with daunorubicin and cladribine, fludarabine with high-dose cytarabine and idarubicin, venetoclax with chemotherapy, cytarabine with idarubicin, daunorubicin, mitoxantrone, midostaurin, or gemtuzumab ozogamicin.

Imlygic

• Documentation of the following is required:
  • diagnosis of unresectable melanoma; and 
  • prescriber is an oncologist; and
  • requested quantity is ≤ four mL/treatment; and
  • unresectable cutaneous, subcutaneous, or nodal lesions; and
  • melanoma is recurrent after initial surgery.

Kimmtrak

• Documentation of the following is required:
  • diagnosis of unresectable or metastatic uveal melanoma; and 
  • member is positive for HLA-A*02:01 genotype
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is refractory to radiation therapy or radiation therapy is not appropriate.

Lumoxiti

• Documentation of the following is required:
  • diagnosis of relapsed or refractory hairy cell leukemia (HCL); and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of HCL with at least two systemic therapies, including at least one purine nucleoside analog (PNA).

Proleukin

• Documentation of the following is required:
  • diagnosis of chronic graft versus host disease (GVHD); and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • disease is refractory to steroid treatment; and
  • for members ≥ 18 years of age, inadequate response or adverse reaction to one or contraindication to both of the following: cyclosporine, tacrolimus.

Please note, requests for all other indications, drug may be subject to additional non-rebate restrictions. Please see MassHealth Pharmacy Operational document for additional information.

Provenge

• Documentation of the following is required:
  • diagnosis of metastatic castration-resistant prostate cancer; and 
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • ECOG score 0-1 (good performance status); and
  • estimated life expectancy > six months; and
  • no hepatic metastases; and
  • no/minimal symptoms; and
  • requested quantity is ≤ three doses (one completed cycle).

Synribo

• Documentation of the following is required:
  • diagnosis of chronic myelogenous leukemia (CML); and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to two of the following or contraindication to all of the following: Bosulif (bosutinib), imatinib, Sprycel (dasatinib), Tasigna (nilotinib); or
    • confirmed T315I mutation.

Tazverik for FL

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested quantity is ≤ eight units/day; and
  • member is ≥ 18 years of age; and
  • one of the following:
    • both of the following:
      • member has FL with an EZH2 mutation (as detected by an FDA-approved test); and
      • prior therapy for the treatment of FL with at least two systemic therapies; or
    • both of the following:
      • member has relapsed or refractory FL; and
      • member has no satisfactory alternative treatment options.

Tazverik for metastatic or locally advanced epithelioid sarcoma

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested quantity is ≤ eight units/day; and
  • member is ≥ 16 years of age. 

Tibsovo for IDH1-mutated AML

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested quantity is < two units/day; and
  • one of the following: 
    • member is ≥ 60 years of age and is not a candidate for chemotherapy; or
    • relapsed or refractory IDH1-mutated AML; or
    • prior treatment of IDH1-mutated AML with at least one of the following systemic therapies: azacitidine, decitabine, glasdegib, cytarabine with daunorubicin and cladribine, fludarabine with high-dose cytarabine and idarubicin, venetoclax with chemotherapy, cytarabine with idarubicin, daunorubicin, mitoxantrone, midostaurin or gemtuzumab ozogamicin.

Tibsovo for IDH1-mutated cholangiocarcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested quantity is ≤ two units/day; and
  • prior treatment of IDH1-mutated cholangiocarcinoma with at least one of the following systemic therapies: cisplatin and gemcitabine, single agent and combination chemotherapies involving 5-fluorouracil, capecitabine, cisplatin, gemcitabine, oxaliplatin, or paclitaxel, entrectinib or larotrectinib (for NTRK gene fusion positive), pembrolizumab (for MSI-H/dMMR tumors).

Venclexta for AML

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member is ≥ 60 years of age; or
    • clinical rationale for use of requested agent instead of intensive induction chemotherapy; and
  • requested agent will be used in combination with azacitidine, decitabine, or low-dose cytarabine.

Venclexta for CLL or SLL

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has not received treatment for CLL or SLL and both of the following:
      • requested agent will be used in combination with Gazyva (obinutuzumab); and
      • contraindication to Imbruvica (ibrutinib); or
    • prior therapy for the treatment of CLL or SLL with at least one systemic therapy and requested agent will be used in combination with Rituxan (rituximab).

Venclexta for multiple myeloma

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has t(11;14) mutation; and
  • inadequate response or adverse reaction to at least one prior chemotherapy regimen for multiple myeloma.

Welireg

• Documentation of the following is required:  
  • diagnosis of von Hippel-Lindau (VHL) disease as confirmed by germline VHL alteration; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested quantity is ≤ three units/day; and
  • member has renal cell carcinoma, central nervous system hemangioblastomas, or pancreatic neuroendocrine tumors; and
  • member is not a candidate for or does not require immediate surgery.

Xpovio

• Documentation of the following is required for monotherapy:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has received at least four prior chemotherapy regimens or contraindication to the use of recommended chemotherapy regimens; and
  • member’s disease is refractory to at least two proteasome inhibitors or member has a contraindication to all proteasome inhibitors; and
  • member’s disease is refractory to at least two immunomodulatory agents or member has a contraindication to all immunomodulatory agents; and
  • member’s disease is refractory to at least one anti-CD38 monoclonal antibody or member has a contraindication to all anti-CD38 monoclonal antibodies; and
  • requested medication will be used in combination with dexamethasone.

• Documentation of the following is required for combination therapy:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one prior chemotherapy regimen for the requested indication; and
  • requested medication will be used in combination with Velcade (bortezomib) or bortezomib and dexamethasone.

• Documentation of the following is required for diagnosis of diffuse large B-cell lymphoma (DLBCL):
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has received at least two prior chemotherapy regimens or contraindication to the use of recommended chemotherapy regimens.

Zelboraf for Erdheim-Chester Disease

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • requested quantity is ≤ eight units/day; and
  • positive BRAF V600 mutation.

Zelboraf for low-grade or high-grade gliomas

• Documentation of the following is required:
  • appropriate diagnosis; and 
  • prescriber is an oncologist; and
  • requested dosing is ≤ 960 mg every 12 hours; and
  • positive BRAF V600E mutation; and
  • requested agent will be used in combination with Cotellic (cobimetinib) ≤ 60 mg/day.

Zelboraf for unresectable or metastatic melanoma

• Documentation of the following is required:
  • appropriate diagnosis; and 
  • prescriber is an oncologist; and
  • requested quantity is ≤ eight units/day; and
  • positive BRAF V600E mutation.

Adcetris for relapsed or refractory Hodgkin Lymphoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member is at high risk of relapse as post autologous hematopoietic stem cell transplantation (auto-HSCT); or
    • inadequate response to auto-HSCT; or
    • member is not a candidate for auto-HSCT and inadequate response or adverse reaction to two prior multi-agent chemotherapy regimens; or
    • clinical rationale as to why the other available treatment regimens cannot be used.

Adcetris for treatment-naïve Hodgkin Lymphoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with doxorubicin, vinblastine, and dacarbazine.

Adcetris for primary cutaneous anaplastic large cell lymphoma (pcALCL) or CD30-expressing mycosis fungoides (MF)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing.

Adcetris for previously untreated CD-30 expressing PTCL, including systemic anaplastic large cell lymphoma (sALCL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested agent will be used with cyclophosphamide, doxorubicin, and prednisone.

Adcetris for sALCL after failure of at least one prior multiagent chemotherapy regimen

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to one prior chemotherapy regimen or agent; or
    • clinical rationale as to why the other available treatment regimens cannot be used.

Halaven for metastatic or recurrent breast cancer 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • two prior chemotherapy regimens that included an anthracycline and a taxane; and
  • inadequate response, adverse reaction or contraindication to vinorelbine (may have been part of prior chemotherapy regimens).

Halaven for unresectable or metastatic liposarcoma 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to an anthracycline-containing regimen.

Polivy

• Documentation of the following is required:
  • diagnosis of diffuse large B-cell lymphoma (DLBCL); and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to at least one systemic therapy, or contraindication to all systemic therapies.

Arzerra for relapsed or refractory CLL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to both of the following: alemtuzumab, fludarabine.

Arzerra for untreated CLL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • contraindication to fludarabine; and
  • one of the following:
    • requested agent will be used in combination with chlorambucil; or
    • clinical rationale as to why the agent will not be used with chlorambucil.

Blincyto

• Documentation of the following is required:
  • diagnosis of ALL; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member with complete remission and MRD positive B-ALL; or 
    • both of the following:
      • Philadelphia chromosome-positive; and
      • inadequate response or adverse reaction to one tyrosine kinase inhibitor for the treatment of ALL; or
    • all of the following:
      • Philadelphia chromosome-negative; and
      • B-cell precursor ALL; and
      • prior therapy for the treatment of ALL with one systemic therapy.

Danyelza

• Documentation of the following is required: 
  • diagnosis of neuroblastoma of bone or bone marrow; and
  • member is ≥ one year of age; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor is high-risk; and
  • member had had partial response, minor response, or stable disease to prior treatment; and
  • requested agent will be used in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF) agent.

Darzalex and Darzalex Faspro for multiple myeloma

• Documenation of the following is required for monotherapy:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and 
  • inadequate response or adverse reaction to one or contraindication to all proteasome inhibitors: bortezomib, Kyprolis (carfilzomib), Ninlaro (ixazomib), Velcade (bortezomib); and
  • inadequate response or adverse reaction to one or contraindication to all of the following immunomodulatory agents; Revlimid (lenalidomide),Thalomid (thalidomide), Pomalyst (pomalidomide); and
  • one of the following:
    • inadequate response or adverse reaction to one proteasome inhibitor and one immunomodulatory agent noted above; or
    • history of a total of three trials with chemotherapy regimens for the requested indication.

• Documentation of the following is required for combination therapy:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • member is newly diagnosed and eligible for transplant; and
      • requested agent will be used in combination with Velcade (bortezomib) or bortezomib and thalidomide and dexamethasone; or
    • both of the following;
      • inadequate response or adverse reaction to at least one prior line of systemic therapy; and
      • requested agent will be used in combination with dexamethasone and at least one other agent for treatment of multiple myeloma (excluding anti-CD38 agents); or
    • all of the following:
      • member is newly diagnosed and ineligible for transplant; and
      • one of the following:
        • requested agent will be used in combination with Revlimid (lenalidomide) and dexamethasone; or
        • requested agent will be used in combination with Velcade (bortezomib) or bortezomib and melphalan and prednisone; or
        • clinical rationale for the use of the requested combination instead of Velcade (bortezomib) or bortezomib and Revlimid (lenalidomide) and dexamethasone.

Darzalex Faspro for light chain amyloidosis

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • concurrent therapy with Velcade (bortezomib) or bortezomib and cyclophosphamide and dexamethasone.

Empliciti

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • inadequate response or adverse reaction to at least one prior chemotherapy regimen for the requested indication; and
      • requested agent will be used in combination with Revlimid (lenalidomide) and dexamethasone; or
    • all of the following:
      • inadequate response or adverse reaction to at least two prior chemotherapy regimens for the requested indication; and
      • inadequate response or adverse reaction to one or contraindication to all of the following proteasome inhibitors: bortezomib, Kyprolis (carfilzomib), Ninlaro (ixazomib), Velcade (bortezomib); and
      • inadequate response, adverse reaction, or contraindication to Revlimid (lenalidomide); and
      • requested medication will be used in combination with Pomalyst (pomalidomide) and dexamethasone.

Gazyva for CLL or SLL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has CLL or SLL without del(17p)/TP53 mutation; or
    • member has CLL or SLL with del(17p)/TP53 mutation AND is treatment naive.

Gazyva for FL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • relapsed or refractory FL after treatment with a rituximab-containing regimen; or
    • concurrent therapy with first-line chemotherapy agent.

Herceptin, Herceptin Hylecta, Herzuma, Kanjinti, Ogivri, Ontruzant, and Trazimera for HER2-overexpressing breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, and Trazimera for HER2-overexpessing metastatic gastric or gastroesophageal adenocarcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with chemotherapy.

Margenza

• Documentation of the following is required: 
  • diagnosis of metastatic HER-2 positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with chemotherapy (capecitabine, eribulin, gemcitabine, or vinorelbine); and
  • inadequate response or adverse reaction to at least two anti-HER-2 based regimens.

Monjuvi for diffuse large B cell lymphoma (DLBCL)

• Documentation of the following is required: 
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all systemic therapies. 

Perjeta 

• Documentation of the following is required:
  • diagnosis of HER-2 positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • for recurrent or stage IV disease, requested agent will be used in combination with Herceptin (trastuzumab) and docetaxel or paclitaxel; or
    • for adjuvant or neoadjuvant chemotherapy, requested agent will be used in combination with trastuzumab and chemotherapy.

Portrazza 

• Documentation of the following is required:
  • diagnosis of advanced or metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer of squamous cell histology; and
  • requested agent will be used in combination with gemcitabine and cisplatin; and
  • medical necessity for use of the requested agent instead of all other clinically appropriate alternatives.

Poteligeo for mycosis fungoides

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • Stage IA disease and member is refractory to skin-directed therapy; or
    • Stage IB to III disease.

Poteligeo for Sézary syndrome

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing.

Riabni, Rituxan, Rituxan Hycela, Ruxience, and Truxima 

• Documentation of the following is required for CLL:
  • appropriate diagnosis; and
  • appropriate dosing.
• Documentation of the following is required for Autoimmune Hemolytic Anemia (AIHA) or IgG-related disease:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to all corticosteroids.
• Documentation of the following is required for graft versus host disease (GVHD):
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to all corticosteroids; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: cyclosporine, tacrolimus, thalidomide.
• Documentation of the following is required for idiopathic membranous nephropathy (IMN):
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to both of the following: chlorambucil, cyclophosphamide; and
  • inadequate response or adverse reaction to one or contraindication to both of the following: cyclosporine, tacrolimus.
• Documentation of the following is required for idiopathic thrombocytopenia purpura (ITP):
  • appropriate diagnosis; and
  • one of the following:
    • splenectomy; or
    • clinical rationale as to why splenectomy was not performed; and
  • inadequate response or adverse reaction to one or contraindication to all corticosteroids.
• Documentation of the following is required for lupus nephritis (LN):
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to both of the following: cyclophosphamide, mycophenolate.
• Documentation of the following is required for minimal change disease:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to both of the following: cyclophosphamide, cyclosporine.
• Documentation of the following is required for multiple sclerosis:
  • appropriate diagnosis; and
  • prescriber is a neurologist or consult notes from a neurologist are provided.
• Documentation of the following is required for neuromyelitis optica spectrum disorder (NMOSD) maintenance therapy:
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to both of the following: azathioprine, mycophenolate.
• Documentation of the following is required for Polymyositis (PM) or Dermatomyositis (DM):
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to one or contraindication to all corticosteroids; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: azathioprine, cyclophosphamide, cyclosporine, methotrexate.
• Documentation of the following is required for Post-Transplantation Lymphoproliferative Disease (PTLD) or Waldenström’s macroglobulinemia:
  • appropriate diagnosis.
• Documentation of the following is required for Systemic Lupus Erythematosus (SLE):
  • appropriate diagnosis; and
  • inadequate response or adverse reaction to two or contraindication to all of the following: azathioprine, cyclophosphamide, cyclosporine, leflunomide, methotrexate, mycophenolate.
• Documentation of the following is required for Thrombotic Thrombocytopenia Purpura (TTP):
  • appropriate diagnosis; and
  • one of the following:
    • member underwent plasma exchange; or
    • clinical rationale as to why plasma exchange was not performed; and
  • inadequate response or adverse reaction to one or contraindication to all corticosteroids.

Riabni, Rituxan, Ruxience, and Truxima for Granulomatosis with Polyangiitis (GPA) or Microscopic Polyangiitis (MPA)

• For induction (initial) therapy, documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to cyclophosphamide; and
  • one of the following:
    • requested agent will be used in combination with a glucocorticoid; or
    • adverse reaction or contraindication to glucocorticoids.
• For maintenance (subsequent) therapy, documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing.

Riabni, Rituxan, Ruxience, and Truxima for Non-Hodgkin’s Lymphoma (NHL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing.

Riabni, Rituxan, Ruxience, and Truxima for rheumatoid arthritis (RA)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to one TNF antagonist; and
  • one of the following:
    • requested agent will be used in combination with methotrexate; or
    • adverse reaction or contraindication to methotrexate.

Rituxan for pediatric members with mature B-cell NHL or mature B-cell acute leukemia (B-AL) 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • member is ≥ six months and < 18 years of age; and
  • requested agent will be used in combination with systemic Lymphome Malin B (LMB) chemotherapy.

Rituxan for Pemphigus Vulgaris (PV)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all systemic corticosteroids; and
  • inadequate response or adverse reaction to one or contraindication to all systemic immunosuppressive therapy (azathioprine, mycophenolate, cyclophosphamide) .

Rituxan Hycela for diffuse large B-cell lymphoma 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing.

Rituxan Hycela for FL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • appropriate dosing.

Sarclisa

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • inadequate response or adverse reaction to one chemotherapy regimen for the requested indication; and
      • requested agent will be used in combination with Kyprolis (carfilzomib) and dexamethasone; or
    • all of the following:
      • inadequate response, adverse reaction, or contraindication to Revlimid (lenalidomide); and
      • history of a total of at least two trials with appropriate regimens for the requested indication; and
      • requested agent will be used in combination with Pomalyst (pomalidomide) and dexamethasone; and
      • inadequate response or adverse reaction to one or contraindication to all of the following proteasome inhibitors: bortezomib, Kyprolis (carfilzomib), Ninlaro (ixazomib), Velcade (bortezomib).

Yervoy for hepatocellular carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with Opdivo (nivolumab); and
  • inadequate response, adverse reaction, or contraindication to sorafenib.

Yervoy for malignant pleural mesothelioma (MPM)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with Opdivo (nivolumab).

Yervoy for metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • PD-L1 expression ≥ 1% and requested agent will be used in combination with Opdivo (nivolumab); or
    • requested agent will be used in combination with Opdivo (nivolumab) and two cycles of platinum doublet chemotherapy.

Yervoy for microsatellitle instability-high (MSI-H)/mismatch repair deficient (dMMR) metastatic colorectal cancer (mCRC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: fluoropyrimidine-based therapy, irinotecan-based therapy, oxaliplatin-based therapy.

Yervoy for renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has clear cell histology; and
  • requested agent will be used in combination with Opdivo (nivolumab).

Yervoy for unresectable advanced or metastatic ESCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with Opdivo (nivolumab) in the first-line setting.

Yervoy for unresectable or metastatic melanoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to one or contraindication to both of the following: Keytruda (pembrolizumab), Opdivo (nivolumab); or 
    • for treatment of unresectable or metastatic melanoma, requested agent will be used in combination with Opdivo (nivolumab) or Keytruda (pembrolizumab).

Zynlonta

• Documentation of the following is required: 
  • diagnosis of relapsed or refractory large B cell lymphoma; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has received at least two prior chemotherapy regimens, or contraindication to the use of recommended chemotherapy regimens.

Rybrevant for advanced or metastatic non-small cell lung cancer 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has EGFR exon 20 insertion mutation; and
  • inadequate response or adverse reaction to at least one
    platinum-based chemotherapy regimen or contraindication
    to the use of platinum-based chemotherapy.

Padcev

• Documentation of the following is required:
  • diagnosis of locally advanced or metastatic urothelial cancer; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or consult notes from an oncologist are provided; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to platinum-based chemotherapy; or
    • contraindication to all platinum-based chemotherapy; and
  • one of the following:
    • inadequate response or adverse reaction to a PD-1 inhibitor or PD-L1 inhibitor therapy; or
    • contraindication to all PD-1 inhibitor and PD-L1 inhibitor therapies.

Bavencio and Keytruda for metastatic Merkel cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Bavencio for first-line treatment of RCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor is clear cell histology; and
  • requested agent will be used in combination with Inlyta (axitinib).

Bavencio for urothelial carcinoma (UC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen; or
    • disease has not progressed following treatment with four-to-six cycles of first-line platinum-containing chemotherapy.

Imfinzi for Stage III NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • disease has not progressed following combination therapy with platinum-based chemotherapy and radiation therapy.

Imfinzi for extensive-stage (ES) SCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has extensive stage disease; and
  • requested agent will be used in combination with etoposide and either carboplatin or cisplatin.

Jemperli for dMMR recurrent or advanced solid tumors

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • cancer is dMMR; and
  • inadequate response, adverse reaction, or contraindication to one prior treatment for dMMR.

Jemperli for recurrent or advanced endometrial cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • cancer is dMMR; and
  • inadequate response, adverse reaction, or contraindication to one line of platinum-based chemotherapy.

Keytruda for non-muscle invasive bladder cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or urologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to BCG; and
  • disease is high-risk with carcinoma in situ.  

Keytruda for high-risk early stage TNBC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with chemotherapy and then continued as a single agent following surgery.

Keytruda for cervical cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • PD-L1 expression [combined positive score (CPS) ≥ 1]; and
  • one of the following:
    • requested agent will be used in combination with chemotherapy, with or without bevacizumab; or
    • requested agent will be used as monotherapy in the setting of disease progression following one systemic chemotherapy regimen.

Keytruda for microsatellite instability-high (MSI-H)/mismatch repair deficient (dMMR) solid tumors or metastatic colorectal cancer (mCRC) 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Keytruda for advanced endometrial carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one prior line of systemic therapy or contraindication to systemic therapy; and
  • member is not a candidate for surgery or radiation; and
  • one of the following:
    • for advanced endometrial carcinoma that is not MSI-H or dMMR, requested agent will be used in combination with Lenvima (lenvatinib); or
    • for advanced endometrial carcinoma that is MSI-H or dMMR, requested agent will be used as monotherapy.

Keytruda for advanced, recurrent or metastatic esophageal or EGJ cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following: 
    • if previously untreated, requested agent will be used in combination with a fluoropyrimidine- and platinum-containing regimen; or
    • requested agent will be used as monotherapy and member had at least one prior line of systemic therapy for squamous cell tumor with PD-L1 (CPS ≥ 10).

Keytruda for recurrent locally advanced or metastatic gastric or GEJ adenocarcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • if microsatellite instability-high (MSI-H)/mismatch repair deficient (dMMR), at least one prior treatment regimen with systemic therapy including fluoropyrimidine- and platinum-containing chemotherapy and if appropriate, HER2/neu-targeted therapy; or
    • if PD-L1-positive, at least two prior treatment regimens with systemic therapy including fluoropyrimidine- and platinum-containing chemotherapy and if appropriate, HER2/neu-targeted therapy; or
    • if previously untreated, locally advanced unresectable or metastatic HER2 positive, requested agent will be used in combination with trastuzumab, fluoropyrimidine-, and platinum-containing chemotherapy.

Keytruda for HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has Child-Pugh Class A; and
  • inadequate response, adverse reaction, or contraindication to sorafenib.

Keytruda and Opdivo for Hodgkin Lymphoma in adult members

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • one of the following:
    • member has progressed after autologous hematopoietic stem cell transplant with or without brentuximab; or
    • member is ineligible for transplant or failure of two or more lines of prior chemotherapy; or
    • member has received allogeneic transplant.

Keytruda and Opdivo for Hodgkin Lymphoma in pediatric members

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member is < 18 years of age; and
  • inadequate response or adverse reaction to two or more lines of prior chemotherapy.

Keytruda for recurrent or metastatic head and neck squamous cell carcinoma (HNSCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen; or
  • cancer is non-nasopharyngeal and one of the following:
    • requested agent is used in combination with a platinum agent (cisplatin, carboplatin) and fluorouracil; or 
    • tumor is PD-L1 positive (CPS ≥ 1).

Keytruda for stage IIB, IIC, or III melanoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used as adjuvant treatment following complete resection.

Keytruda and Opdivo for unresectable or metastatic melanoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Keytruda for stage III NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • PD-L1 expression [tumor proportion score (TPS) ≥ 1%]; and
  • requested agent will be used in combination with carboplatin and either pemetrexed or paclitaxel.

Keytruda for unresectable or metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • requested agent will be used in combination with pemetrexed and either carboplatin or cisplatin for nonsquamous NSCLC in the first-line setting; or
    • requested agent will be used in combination with carboplatin and either paclitaxel or albumin-bound paclitaxel for squamous NSCLC in the first-line setting; or
    • PD-L1 expression and an inadequate response, adverse reaction or contraindication to a platinum-containing regimen; or
    • all of the following:
      • PD-L1 expression ≥ 50% of tumor cells; and
      • member does not have EGFR or ALK genomic tumor aberrations; and
      • member has not had prior systemic chemotherapy for this indication.

Keytruda for primary mediastinal B-cell lymphoma (PMBCL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to two systemic chemotherapy regimens, or contraindication to the use of systemic chemotherapy.

Keytruda for advanced RCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • tumor is clear cell histology and one of the following:
      • requested agent will be used in combination with Inlyta (axitinib); or
      • requested agent will be used in combination with Lenvima (lenvatinib); or
      • requested agent will be used as adjuvant treatment following nephrectomy; or
    • tumor is non-clear cell histology and inadequate response or adverse reaction to one of the following, or contraindication to both of the following: Cabometyx (cabozantinib), sunitinib.

Keytruda for metastatic squamous cell carcinoma of the esophagus (ESCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor expresses PD-L1 (CPS ≥ 10); and
  • inadequate response, adverse reaction, or contraindication to at least one line of systemic therapy.

Keytruda and Libtayo for metastatic or locally advanced cutaneous squamous cell carcinoma (CSCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing;  and
  • member is ≥ 18 years of age; and
  • member is not a candidate for surgery and/or radiation therapy.

Keytruda for tumor mutational burden-high (TMB-H) cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing;  and
  • tumor has ≥ 10 mutations/megabase.

Keytruda for unresectable locally advanced or metastatic triple-negative breast cancer (TNBC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is PD-L1 positive (CPS ≥ 10); and
  • requested agent will be used in combination with one of the following: paclitaxel protein-bound, paclitaxel, or gemcitabine plus carboplatin.

Keytruda for locally advanced or metastatic UC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • if treatment-naïve, PD-L1 expression with CPS ≥ 10; or
    • member is not a candidate for any platinum-containing chemotherapy due to poor performance status; or
    • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen.

Libtayo for basal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one hedgehog pathway inhibitor, or contraindication to the use of a hedgehog pathway inhibitor.

Libtayo for NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor has PD-L1 expression ≥ 50%; and
  • one of the following:
    • member has locally advanced cancer and is not a candidate for surgical resection or definitive chemoradiation; or
    • member has metastatic disease.

Opdivo for RCC 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • tumor is clear cell histology and requested agent will be used in combination with Yervoy (ipilimumab); or
    • tumor is clear cell histology and requested agent will be used in combination with Cabometyx (cabozantinib); or
    • tumor is clear cell histology and member has received prior anti-angiogenic therapy and requested agent will be used as monotherapy; or
    • tumor is non-clear cell histology and inadequate response or adverse reaction to one of the following, or contraindication to both of the following: Cabometyx (cabozantinib), sunitinib.

Opdivo for completely resected esophageal or gastroesophageal junction (GEJ) cancer 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has residual pathologic disease; and
  • member has received neoadjuvant chemoradiotherapy (CRT).

Opdivo for advanced or metastatic gastric cancer, GEJ cancer or esophageal adenocarcinoma 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is HER-2 negative; and
  • requested agent is to be used in combination with a fluoropyrimidine- and platinum-containing regimen.

Opdivo for HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member has Child-Pugh Class A or B; and
  • inadequate response, adverse reaction, or contraindication to sorafenib.

Opdivo for recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen.

Opdivo for MPM

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with Yervoy (ipilimumab).

Opdivo for MSI-H/dMMR mCRC 

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a fluoropyrimidine, oxaliplatin, and irinotecan-containing regimen.

Opdivo for resectable NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in the neoadjuvant setting; and
  • requested agent will be used in combination with one of the following:
    • carboplatin and paclitaxel; or
    • cisplatin and pemetrexed; or
    • cisplatin and gemcitabine.

Opdivo for unresectable or metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen; or
    • requested agent will be used in combination with ipilimumab and either: pemetrexed and carboplatin, pemetrexed and cisplatin, or paclitaxel and carboplatin; or
    • tumor has PD-L1 expression ≥ 1% and the requested agent is used in combination with ipilimumab.

Opdivo for unresectable advanced, recurrent, or metastatic squamous cell carcinoma of the esophagus (ESCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has received prior fluoropyrimidine-based and platinum-based chemotherapy; or
    • requested agent will be used in combination with a fluoropyrimidine- and platinum-based chemotherapy regimen in the first-line setting; or
    • requested agent will be used in combination with Yervoy (ipilimumab) in the first-line setting.

Opdivo for UC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • disease progression during or following a platinum-containing regimen; or
    • requested agent will be used as adjuvant treatment following radical resection of the bladder or parts of the urinary tract.

Tecentriq for hepatocellular carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with bevacizumab; and
  • member has Child-Pugh Class A.

Tecentriq for stage II to IIIA NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor has PD-L1 expression ≥ 1%; and
  • requested agent will be used as adjuvant treatment following complete resection and platinum-based chemotherapy. 

Tecentriq for unresectable or metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response, adverse reaction, or contraindication to a platinum-containing regimen; or
    • requested agent will be used in combination with Avastin (bevacizumab), paclitaxel, and carboplatin in the first-line setting for nonsquamous NSCLC; or 
    • tumor has PD-L1 expression ≥ 50%; or
    • requested agent will be used in combination with albumin-bound paclitaxel and carboplatin in the first-line setting for nonsquamous NSCLC.

Tecentriq for extensive-stage (ES) SCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has extensive stage disease; and
  • requested agent will be used in combination with carboplatin and etoposide.

Tecentriq for UC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • if treatment-naïve, PD-L1-stained tumor-infiltrating immune cells covering ≥ 5% of tumor area, or member is not a candidate for any platinum-containing chemotherapy due to poor performance status.

Tecentriq for unresectable or metastatic melanoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • positive BRAF V600E or V600K mutation; and
  • documentation that the requested agent will be used in combination with Cotellic (cobimetinib) and Zelboraf (vemurafenib); and
  • inadequate response or adverse reaction to one of the following or contraindication to all of the following: 
    • Tafinlar (dabrafenib) + Mekinist (trametinib); or
    • Cotellic (cobimetinib) + Zelboraf (vemurafenib); or
    • Braftovi (encorafenib) + Mektovi (binimetinib).

Lynparza for BRCA-mutated breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has deleterious or suspected deleterious germline BRCA mutation; and
  • member has completed neoadjuvant or adjuvant chemotherapy; and
  • requested quantity is ≤ four tablets/day.

Lynparza for Homologous recombination repair (HRR) gene-mutated mCRPC

• Documentation of the following is required: 
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has deleterious or suspected deleterious germline or somatic HRR gene mutation; and
  • inadequate response or adverse reaction to one of the following or contraindication to all of the following: 
    • Xtandi (enzalutamide); or
    • Yonsa (abiraterone); or
    • Zytiga (abiraterone); and
  • requested quantity is ≤ four tablets/day.

Lynparza for ovarian cancer

• For progressive disease, documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has confirmed or suspected deleterious BRCA germline mutation; and
  • one of the following:
    • inadequate response or adverse reaction to at least two prior chemotherapy regimens; or
    • contraindication to the use of recommended chemotherapy regimens; and
  • requested quantity is ≤ four tablets/day.

• For maintenance therapy as monotherapy, documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has deleterious or suspected deleterious germline or somatic BRCA-mutated (gBRCAm or sBRCAm) and has completed one line of platinum-based chemotherapy; or
    • member has completed two or more lines of platinum-based chemotherapy; or
    • contraindication to the use of recommended chemotherapy regimens; and
  • member has achieved a partial or complete response requiring maintenance therapy; and
  • requested quantity is ≤ four tablets/day.

• For maintenance therapy as combination therapy, documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following: 
    • cancer has a deleterious germline or somatic mutation in BRCA1 or BRCA2; or
    • cancer is homologous recombination deficiency (HRD) positive status; and 
  • member has achieved a partial or complete response on Avastin (bevacizumab) requiring maintenance therapy; and
  • requested agent will be used in combination with Avastin (bevacizumab); and
  • requested quantity is ≤ four tablets/day.

Lynparza for pancreatic adenocarcinoma (maintenance therapy)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has deleterious or suspected deleterious gBRCA mutation; and
  • member has disease which has not progressed on at least 16 weeks of a first-line platinum-based chemotherapy regimen; and
  • requested quantity is ≤ four tablets/day.

Rubraca for BRCA-mutated mCRPC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has deleterious (germline and/or somatic) BRCA mutation; and 
  • inadequate response or adverse reaction to one of the following or contraindication to all of the following:
    • Xtandi (enzalutamide); or
    • Yonsa (abiraterone); or
    • Zytiga (abiraterone); and
  • inadequate response, adverse reaction, or contraindication to taxane-based chemotherapy; and
  • requested quantity is ≤ four units/day.

Rubraca for ovarian cancer 

• For maintenance therapy, documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • member has completed two or more lines of platinum-based chemotherapy; or
    • contraindication to the use of recommended chemotherapy regimens; and
  • member has achieved a partial or complete response requiring maintenance therapy; and
  • requested quantity is ≤ four tablets/day.

Talzenna

• Documentation of the following is required:
  • diagnosis of BRCA-mutated localyly advanced or metastatic breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer has deleterious or suspected deleterious germline BRCA mutation; and
  • one of the following:
    • for the 0.5 mg, 0.75 mg, or 1 mg capsule, requested quantity is ≤ one tablet/day; or
    • for the 0.25 mg capsule, requested quantity is ≤ three tablets/day.

Zejula for ovarian cancer

• For maintenance therapy, documentation of the following is required:
  • appropriate diagnosis; and 
  • appropriate dosing; and
  • prescriber is an oncologist; and
  • one of the following:
    • member has completed one or more lines of platinum-based chemotherapy; or
    • contraindication to the use of recommended chemotherapy; and
  • member has achieved a partial or complete response requiring maintenance therapy; and
  • requested quantity is ≤ three units/day.

• For progressive disease, documentation of the following is required:
  • appropriate diagnosis; and 
  • appropriate dosing; and
  • prescriber is an oncologist; and
  • one of the following:
    • member has completed three or more lines of platinum-based chemotherapy; or
    • contraindication to the use of recommended chemotherapy; and 
  • one of the following: 
    • cancer has a deleterious germline or somatic mutation in BRCA1 or BRCA2; or
    • cancer is homologous recombination deficient (HRD) positive status; and
  • requested quantity is ≤ three units/day. 

Kyprolis

• Documentation of the following is required for monotherapy:
  • diagnosis of multiple myeloma; and
  • appropriate dosing; and
  • prescriber is an oncologist or hematologist; and
  • inadequate response, adverse reaction or contraindication to at least one prior chemotherapy regimen for the requested indication.

• Documentation of the following is required for combination therapy:
  • diagnosis of multiple myeloma; and
  • appropriate dosing; and
  • prescriber is an oncologist or hematologist; and
  • requested agent will be used in combination with dexamethasone with or without additional agents for the treatment of multiple myeloma (excluding proteasome inhibitors).

Ninlaro

• Documentation of the following is required:
  • diagnosis of multiple myeloma; and
  • appropriate dosing; and
  • prescriber is an oncologist or hematologist; and
  • inadequate response or adverse reaction to at least one prior chemotherapy regimen for the requested indication; and
  • requested agent will be used in combination with dexamethasone with or without additional agents for the treatment of multiple myeloma (excluding proteasome inhibitors); and
  • requested quantity is ≤ three capsules/28 days.

Etopophos

• Documentation of the following is required:
  • diagnosis of small cell lung cancer or testicular cancer; and
  • prescriber is an oncologist or hematologist; and
  • member is ≥ 18 years of age; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to an etoposide product available without PA.

Onivyde

• Documentation of the following is required:
  • diagnosis of metastatic adenocarcinoma of the pancreas; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • member is ≥ 18 years of age; and
  • requested agent will be used in combination with fluorouracil and leucovorin; and
  • inadequate response, adverse reaction, or contraindication to the use of a gemcitabine- or fluoropyrimidine-based chemotherapy regimen.

Trodelvy for metastatic triple negative breast cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to at least two prior therapies.

Trodelvy for locally advanced or metastatic urothelial cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to a platinum containing regimen plus a PD-1 or PD-L1 inhibitor.

Rozlytrek for solid tumors with neurotrophic receptor tyrosine kinase (NTRK) gene fusion without a known acquired resistance mutation

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • tumor is metastatic; or
    • member is not a candidate for surgical resection; and
  • requested quantity is ≤ three units/day for 200 mg capsule, or two units/day for 100 mg capsule; and
  • one of the following:
    • requested agent is first-line for the requested indication; or
    • member has no satisfactory alternative treatment options; or
    • disease has progressed following at least one first-line treatment for the requested indication (e.g., chemotherapy, radiation, surgical intervention).

Rozlytrek for ROS1-positive metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is ROS1 positive; and
  • requested quantity is ≤ three units/day for 200 mg capsule, or two units/day for 100 mg capsule.

Vitrakvi

• Documentation of the following is required:
  • diagnosis of solid tumors with NTRK gene fusion without a known acquired resistance mutation; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • tumor is metastatic; or
    • member is not a candidate for surgical resection; and
  • one of the following:
    • requested agent is first-line for the requested indication; or
    • member has no satisfactory alternative treatment options; or
    • disease has progressed following at least one first-line treatment for the requested indication (e.g., chemotherapy, radiation, surgical intervention); and
  • requested quantity is ≤ two units/day for 100 mg capsule, six units/day for 25 mg capsule, or ten mL/day for oral solution; and
  • if the request is for oral solution formulation, medical necessity for the use of an oral solution formulation (e.g., swallowing disorder) must be provided.

Alecensa

• Documentation of the following is required:
  • diagnosis of metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is anaplastic lymphoma kinase (ALK)-positive; and
  • requested quantity is ≤ eight units/day.

Alunbrig

• Documentation of the following is required:
  • diagnosis of metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is ALK-positive; and
  • one of the following:
    • for 30 mg tablets, requested quantity is ≤ two units/day; or
    • for 90 mg or 180 mg tablets, or the 90 mg-180 mg tablet pack, requested quantity is ≤ one unit/day.

Ayvakit for unresectable or metastatic GIST

• Documentation of the following :
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has disease harboring a PDGFRA exon 18 mutation (including PDGFRA D842V mutations); and
  • requested quantity is ≤ one unit/day.

Ayvakit for advanced systemic mastocytosis (AdvSM), systemic mastocytosis (SM) with associated hematological neoplasm, mast cell leukemia

• Documentation of the following:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • requested quantity is ≤ one unit/day; and
  • one of the following:
    • D816V c-Kit mutation positive (as determined by an FDA-approved test); or
    • both of the following:
      • member has aggressive SM without the D816V c-Kit mutation (as determined by an FDA-approved test) or with c-Kit mutation status unknown; and
      • inadequate response, adverse reaction, or contraindication to imatinib.

Bosulif

• Documentation of the following is required:
  • diagnosis of CML; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has chronic phase Philadelphia chromosome-positive (Ph+) CML; or
    • inadequate response or adverse reaction to one prior therapy for CML or contraindication to all other therapies for CML.

Brukinsa and Calquence for MCL

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of MCL.

Brukinsa for MZL

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of MZL with at least one anti-CD20 monoclonal antibody-based regimen.

Brukinsa for Waldenstrom's macroglobulinemia (WM)

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing.

Cabometyx for advanced renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • member has clear cell histology; and
      • requested agent will be used in combination with Opdivo; or
    • all of the following: 
      • member has clear cell histology; and 
      • member has received a previous treatment in the metastatic setting; and 
      • requested agent will be used as monotherapy; or
    • member has non-clear cell histology; and
  • requested quantity is ≤ one unit/day.

Cabometyx for locally recurrent, advanced, and/or metastatic differentiated thyroid carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one of the following, or contraindication to both of the following: Lenvima (lenvatinib), sorafenib; and
  • requested quantity is ≤ one unit/day; and
  • one of the following:
    • member is refractory to radioactive iodine; or
    • radioactive iodine treatment is not appropriate.

Cabometyx for unresectable HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to sorafenib; and
  • requested quantity is ≤ one unit/day.

Calquence for CLL/SLL

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member is treatment naive and one of the following:
      • requested agent will be used in combination with obinutuzumab; or
      • clinical rationale for use of the requested agent as monotherapy; or
    • member has relapsed disease, refractory disease, or prior therapy for the treatment of CLL/SLL.

Caprelsa

• Documentation of the following is required:
  • diagnosis of symptomatic or progressive medullary thyroid cancer; and
  • one of the following:
    • for 100 mg tablets, requested quantity is ≤ two units/day; or
    • for 300 mg tablets, requested quantity is ≤ one unit/day; or
    • medical necessity for exceeding quantity limit of two units/day for 100 mg tablets or one unit/day for 300 mg tablets.

Cometriq

• Documentation of the following is required:
  • diagnosis of symptomatic or progressive medullary thyroid cancer; and
  • one of the following:
    • requested dose is ≤ 140 mg/day; or
    • medical necessity for exceeding the 140 mg/day dose.

erlotinib for advanced or metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations; and
  • requested quantity is ≤ one unit/day.

erlotinib for advanced or metastatic pancreatic cancer

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member will be using the requested agent in combination with gemcitabine; and
  • requested quantity is ≤ one unit/day.

Fotivda 

• Documentation of the following is required:
  • diagnosis of advanced renal cell carcinoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor is clear cell histology; and
  • inadequate response or adverse reaction to two or contraindication to all systemic therapies; and
  • requested quantity is ≤ one unit/day.

Iclusig for ALL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one or contraindication to all of the following: imatinib, Sprycel (dasatinib), Tasigna (nilotinib).

Iclusig for CML

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • inadequate response or adverse reaction to two or contraindication to all of the following: Bosulif (bosutinib), imatinib, Sprycel (dasatinib), Tasigna (nilotinib); or
    • confirmed T315I mutation.

Imbruvica for cGVHD

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to systemic glucocorticoids.

Imbruvica for CLL, SLL, CLL/SLL with 17p deletion, and WM

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing.

Imbruvica for central nervous system (CNS) lymphoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to a methotrexate-based regimen for the treatment of CNS lymphoma.

Imbruvica for MCL and MZL

• Documentation of the following is required:
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • prior therapy for the treatment of MCL or MZL with at least one systemic therapy.

Inlyta

• Documentation of the following is required:
  • diagnosis of advanced renal cell carcinoma; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • tumor is clear cell histology; and
      • requested agent will be used in combination with Bavencio (avelumab) or Keytruda (pembrolizumab); or
    • both of the following:
      • requested agent will be used as monotherapy; and
      • member has failed one prior line of systemic therapy.

Iressa

• Documentation of the following is required:
  • diagnosis of metastatic NSCLC; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member has EGFR mutations; and
  • requested quantity is ≤ one unit/day.

Lenvima for advanced renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • one of the following:
    • all of the following: 
      • tumor is clear cell histology; and
      • requested agent will be used in combination with everolimus; and
      • member has failed one first-line therapy for advanced renal cell carcinoma; or
    • both of the following: 
      • tumor is clear cell histology; and
      • requested agent will be used in combination with Keytruda (pembrolizumab); or
    • tumor is non-clear cell histology and inadequate response or adverse reaction to one or contraindication to both of the following: Cabometyx, sunitinib.

Lenvima for differentiated thyroid cancer (DTC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Lenvima for endometrial carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response or adverse reaction to one prior line of systemic therapy or contraindication to systemic therapy; and 
  • requested agent will be used in combination with Keytruda (pembrolizumab).

Lenvima for unresectable hepatocellular carcinoma (HCC)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing.

Rydapt for FLT3-mutated acute myeloid leukemia (AML)

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • for induction therapy, requested agent will be used in combination with cytarabine and daunorubicin; or
    • for consolidation therapy, requested agent will be used in combination with cytarabine.

Rydapt for aggressive systemic mastocytosis (SM), SM with associated hematological neoplasm, and mast cell leukemia

• Documentation of the following is required:  
  • appropriate diagnosis; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • both of the following:
      • member has aggressive SM without the D816V c-Kit mutation (as determined by an FDA-approved test) or with c-Kit mutation status unknown; and
      • inadequate response, adverse reaction, or contraindication to imatinib; or
    • D816V c-Kit mutation positive (as determined by an FDA-approved test).

Scemblix

• Documentation of the following is required:
  • diagnosis of CML; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • confirmed T315I mutation; or
    • inadequate response or adverse reaction to two or contraindication to all of the following: Bosulif (bosutinib), Iclusig (ponatinib), imatinib, Sprycel (dasatinib), Tasigna (nilotinib).

sorafenib for advanced renal cell carcinoma, DTC, or unresectable HCC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested quantity is ≤ four units/day.

sorafenib for FLT3-ITD mutated AML

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • member has relapsed/refractory disease; and
  • requested agent will be used in combination with a hypomethylating agent (5-azacytidine or decitabine); and
  • requested quantity is ≤ four units/day.

sunitinib for advanced renal cell carcinoma and advanced pancreatic neuroendocrine tumors (PNET)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested quantity is ≤ one unit/day.
   

sunitinib for GIST

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to imatinib; and
  • requested quantity is ≤ one unit/day.

sunitinib for renal cell carcinoma (adjuvant setting)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • tumor is clear cell histology; and
  • requested quantity is ≤ one unit/day.
   

Tukysa 

• Documentation of the following is required:
  • diagnosis of advanced unresectable or metastatic HER2-positive breast cancer; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested agent will be used in combination with trastuzumab and capecitabine; and
  • inadequate response or adverse reaction to one anti-HER2-based regimen; and
  • requested quantity is ≤ four units/day.

Turalio

• Documentation of the following is required:
  • diagnosis of tenosynovial giant cell tumor; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • member is not a candidate for surgery.

Votrient for advanced renal cell carcinoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • requested quantity is ≤ four units/day.

Votrient for soft tissue sarcoma

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • inadequate response, adverse reaction, or contraindication to prior chemotherapy; and
  • requested quantity is ≤ four units/day.

Votrient for GIST

• Documentation of the following is required:
  • appropriate diagnosis; and
  • inadequate response, adverse reaction, or contraindication to all of the following: imatinib, Qinlock (ripretinib), sunitinib, Stivarga (regorafenib); and
  • requested quantity is ≤ four units/day.

Xalkori for systemic anaplastic large cell lymphoma (ALCL)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • member is ≥ one and < 22 years of age; and
  • appropriate dosing; and
  • cancer is ALK-positive; and
  • one of the following:
    • member has relapsed or refractory disease to one prior agent or regimen; or 
    • clinical rationale as to why the other available treatment regimens cannot be used; and
  • requested quantity is ≤ four units/day.

Xalkori for unresectable, recurrent, or refractory inflammatory myofibroblastic tumors (IMT)

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • member is ≥ one year of age; and
  • appropriate dosing; and
  • cancer is ALK-positive.

Xalkori for ALK-positive or ROS1 positive metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is ALK-positive or ROS1 positive; and
  • requested quantity is ≤ two units/day.

Xalkori for MET positive amplification metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • cancer is MET positive amplification; and
  • requested quantity is ≤ two units/day.

Xospata

• Documentation of the following is required:  
  • diagnosis of FLT3-mutated AML; and
  • member is ≥ 18 years of age; and
  • prescriber is an oncologist or hematologist; and
  • appropriate dosing; and
  • one of the following:
    • member has received at least one line of treatment; or
    • member has relapsed or refractory disease; and
  • requested quantity is ≤ three units/day.

Zykadia for ALK-positive metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • appropriate dosing; and
  • cancer is ALK-positive; and
  • requested quantity is ≤ three units/day.

Zykadia for ROS1-rearrangement metastatic NSCLC

• Documentation of the following is required:
  • appropriate diagnosis; and
  • prescriber is an oncologist; and
  • cancer is ROS1-rearrangement; and
  • requested quantity is ≤ three units/day.