CurrentCentenePolicy CP PHAR.68
Gefitinib (Iressa) clinical coverage policy
Defines medical necessity criteria, initial and continuation approval requirements, dosing limits, formulary/generic redirection, approval durations, and exclusions for gefitinib (Iressa) across Commercial, HIM, and Medicaid lines of business for treatment of NSCLC.
Policy Summary
PayerCentene
PolicyGefitinib (Iressa) clinical coverage policy
Policy CodePolicy CP PHAR.68
Change TypeRevised (annual reviews; some past material revisions)
Effective Date11.16.16
Next Review Date
Key ActionProvider must submit documentation supporting that the member meets all approval criteria, including EGFR mutation status and response to therapy.
POLICY UPDATE CHANGES
Annual reviews with no significant changes noted for multiple years; most recent P&T approval date 05.25 (2025) stating no significant changes.
2Q 2022 annual review added criterion for use as single-agent therapy for NSCLC and revised commercial approval durations.
2Q 2021 annual review added oral oncology generic redirection language.
1FDA-approved indication(s) (NSCLC with sensitizing EGFR mutations)
250 mg/dayStandard dose
500 mg/dayMax dose with strong CYP3A4 inducer
30 days