CurrentCignaPolicy N/A

Oncology (Oral -Neurotrophic Tyrosine Receptor Kinase Gene Fusion) -Rozlytrek Prior Authorization Policy

Prior authorization policy for Rozlytrek (entrectinib capsules and oral pellets) describing coverage criteria for FDA-approved indications (ROS1-positive NSCLC and NTRK gene fusion solid tumors) and select other uses with supportive evidence (pediatric diffuse high-grade gliomas). Approvals are for 1 year when criteria are met.

Policy Summary

PayerCigna

PolicyOncology (Oral -Neurotrophic Tyrosine Receptor Kinase Gene Fusion) -Rozlytrek Prior Authorization Policy

Policy CodePolicy N/A

Change TypeRevised & Added indications; administrative title change

Effective Date

Next Review Date

Key ActionPrior Authorization is recommended/required for prescription benefit coverage of Rozlytrek; approvals are provided for 1 year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Added note to refer NSCLC with NTRK gene fusion to Solid Tumors indication; expanded examples and added adult glioma to solid tumors.

Added Pediatric Diffuse High-Grade Gliomas as an other use with supportive evidence.

Added oral pellets dosage form to the policy and expanded age indication for solid tumors to ≥ 1 month.

Policy name changed to include 'Neurotrophic Tyrosine Receptor Kinase Gene Fusion' descriptive text.

2FDA-approved indication groups (NSCLC, Solid tumors)

1Other uses with supportive evidence (Pediatric diffuse high-grade gliomas)

1 year