CurrentCignaPolicy N/A

POLICY: Oncology (Oral -Epidermal Growth Factor Receptor Inhibitor) -Gefitinib Prior Authorization Policy

Prior authorization policy for gefitinib (Iressa) oral tablets for prescription benefit coverage under Cigna-administered plans, defining medical necessity criteria for FDA-approved indications and exclusions.

Policy Summary

PayerCigna

PolicyOncology (Oral -Epidermal Growth Factor Receptor Inhibitor) -Gefitinib Prior Authorization Policy

Policy CodePolicy N/A

Change TypeName update; terminology clarification

Effective DateApr 21, 2025

Next Review Date

Key ActionPrior Authorization is recommended for gefitinib; approvals are provided for 1 year when criteria are met and providers must document EGFR mutation-positive status detected by an approved test.

SourceLink

POLICY UPDATE CHANGES

Policy name changed from 'Oncology - Gefitinib PA Policy' to 'Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gefitinib PA Policy' effective 04/21/2025.

Deleted the descriptor 'sensitizing' while referring to EGFR mutations in criteria and note.

1Covered Indications

5Example EGFR mutations listed

12Approval duration (months)

Coverage Summary

Scope: Prior authorization policy for gefitinib (Iressa) oral tablets for prescription benefit coverage under Cigna-administered plans, defining medical necessity criteria for FDA-approved indications and exclusions. Subject: Gefitinib (Iressa) prior authorization for NSCLC. Coverage stance: covered_with_criteria. Status: CURRENT. Effective date: 2025-04-21. Last review date: 2025-09-03.

Quick facts

Covered Indications1

Example EGFR mutations listed5

Approval duration12 months

PayerCigna

Policy titleOncology (Oral -Epidermal Growth Factor Receptor Inhibitor) -Gefitinib Prior Authorization Policy

Effective date04/21/2025

Provider Actions

Prior Authorization

Prior authorization required

Prior Authorization is recommended for prescription benefit coverage of gefitinib; approvals are provided for a duration of 1 year when criteria are met.

Documentation Required

Documentation of EGFR mutation and test

Provider must document EGFR mutation-positive status and that the mutation was detected by an approved test (include specific mutation if applicable).

exon 19 deletions
exon 21 L858R
L861Q
G719X
S768I

Background & Definitions

Gefitinib is an EGFR tyrosine kinase inhibitor indicated for the first-line treatment of metastatic non-small cell lung cancer (NSCLC) in patients whose tumors have EGFR exon 19 deletions or exon 21 (L858R) substitution mutations as detected by an FDA-approved test. NCCN lists osimertinib (Tagrisso) as the preferred first-line therapy; gefitinib and other EGFR TKIs are listed as useful in certain circumstances and gefitinib is recommended for some less common EGFR mutations (L861Q, G719X, S768I).

Definitions

EGFR mutation-positivePresence of EGFR mutations such as exon 19 deletions, exon 21 (L858R) substitution mutations, L861Q, G719X, or S768I detected by an FDA-approved test.

Revision History

04/21/2025policy_name_changeLatest

Policy name changed from 'Oncology - Gefitinib PA Policy' to 'Oncology (Oral - Epidermal Growth Factor Receptor Inhibitor) - Gefitinib PA Policy' effective 04/21/2025.

04/21/2025text_revisionLatest

Deleted the descriptor 'sensitizing' while referring to EGFR mutations in criteria and note.

Policy Summary

PayerCigna

PolicyOncology (Oral -Epidermal Growth Factor Receptor Inhibitor) -Gefitinib Prior Authorization Policy

Policy CodePolicy N/A

Change TypeName update; terminology clarification

Effective DateApr 21, 2025

Next Review Date

SourceLink

On This Page

OpenPayer

POLICY: Oncology (Oral -Epidermal Growth Factor Receptor Inhibitor) -Gefitinib Prior Authorization Policy

Coverage Summary

Initial Therapy Criteria (FDA‑Approved Indication)

Provider Actions

Applicable Codes

Clinical Evidence & References

Background & Definitions

Revision History