CurrentMass General Brigham Health PlanPolicy N/A

Kinase Inhibitors Cosela (trilaciclib) Effective 09/01/2025

Pharmacy benefit prior authorization and quantity-limit policy governing use of Cosela (trilaciclib) for reduction of chemotherapy-induced myelosuppression in adult patients with extensive-stage small cell lung cancer (ES-SCLC); includes initial and continuation criteria, approval durations, contact info, and historical updates aligning with MassHealth criteria.

Policy Summary

PayerMass General Brigham Health Plan

PolicyKinase Inhibitors Cosela (trilaciclib) Effective 09/01/2025

Policy CodePolicy N/A

Change TypeRevised (alignment with MassHealth)Clarified (reauthorization duration)

Effective DateSep 1, 2025

Next Review Date

Key ActionProviders must obtain prior authorization for Cosela under the pharmacy benefit and submit documentation of diagnosis, prescriber specialty, dosing, age, and concurrent chemotherapy regimen; submit timely reauthorization requests with required documentation to avoid coverage lapse.

SourceLink

POLICY UPDATE CHANGES

Separated out MBO agent (Cosela) from Kinase Inhibitor policy and aligned criteria with MassHealth for HOPA implementation.

Clarified Cosela reauthorization approval duration to 3 months (historical note).

1Indication covered

>=18Minimum age

6mInitial approval

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Coverage Summary

Policy status: covered_with_criteria — Cosela (trilaciclib) is covered under the pharmacy benefit for reduction of chemotherapy‑induced myelosuppression in adult patients with extensive‑stage small cell lung cancer (ES‑SCLC) when the policy’s prior authorization and clinical criteria are met. Scope: pharmacy benefit prior authorization and quantity‑limit policy governing use of Cosela for this indication, including required documentation, prescriber specialty, and approval durations aligned with the MassHealth UPPL.

Key Thresholds

Age>= 18 years

Initial approval duration6 months

Reauthorization duration3 months

Indication coveredDecrease incidence of chemotherapy-induced myelosuppression for adult patients with ES-SCLC when given prior to platinum/etoposide- or topotecan-containing regimens

Initial Therapy Criteria

Authorization — Initial Therapy

Authorization may be granted if the member meets ALL following criteria and documentation has been submitted:

Diagnosis of extensive-stage small cell lung cancer (ES-SCLC)
Prescriber is an oncologist
Dosing: Appropriate dosing
Age: Member is >= 18 years of age>= 18 years
Document states 'Member is 2 18 years of age' — interpreted as ≥ 18

Case-by-case / New-to-Plan Continuation

Authorization — Case-by-case (New-to-Plan Continuation)

Authorization may be reviewed on a case by case basis for members who are new to the plan currently receiving treatment with requested medication, excluding when the product is obtained as samples or via manufacturer's patient assistance programs

New-to-plan receiving treatment: Member is new to the plan and currently receiving the requested medication (documentation required)

Continuation of Therapy Criteria

Continuation of Therapy

Resubmissions should be verified for continuation of chemotherapy cycles with either a platinum/etoposide-containing regimen or a topotecan-containing regimen:

Ongoing combination therapy: Documentation of ongoing combination with a platinum/etoposide- or topotecan-containing chemotherapy regimen for each resubmission

Limitations / Approval Durations

Initial approval duration: Initial approvals will be granted for 6 months6 months

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required

Providers must obtain prior authorization for Cosela under the pharmacy benefit; requests may be reviewed case-by-case for members new to the plan who are already receiving treatment; documentation of diagnosis, prescriber specialty, dosing, age, and concurrent chemotherapy regimen must be submitted.

Diagnosis of extensive-stage small cell lung cancer (ES-SCLC)
Prescriber specialty: oncologist
Appropriate dosing
Member is ≥ 18 years of age
Concurrent use with a platinum/etoposide- or topotecan-containing chemotherapy regimen

Documentation Required

Documentation of ongoing chemotherapy

For continuation/reauthorization, providers must verify and document continuation of chemotherapy cycles with a platinum/etoposide- or topotecan-containing regimen.

Applicable Codes & Benefit Alignment

Relevant benefit/programmixed

MassHealth UPPL

Alignment with MassHealth drug list and criteria; additional agents available through the pharmacy benefit per MassHealth Drug List

Clinical Evidence & References

Key evidence/reference: Package insert — G1 Therapeutics, Inc; 2023 Aug is cited as the primary reference. The policy aligns coverage criteria with the MassHealth UPPL and follows MassHealth‑aligned updates and review history noted in the policy.

Background

Background: Cosela (trilaciclib) is indicated to decrease the incidence of chemotherapy‑induced myelosuppression when administered prior to a platinum/etoposide‑containing regimen or a topotecan‑containing regimen for adult patients with extensive‑stage small cell lung cancer (ES‑SCLC). This policy aligns coverage and criteria with the MassHealth UPPL and requires prior authorization under the pharmacy benefit; documentation of diagnosis, prescriber specialty, dosing, age, and concurrent chemotherapy regimen is required. Initial approvals are granted for 6 months and reauthorizations for 3 months.

Definitions: ES‑SCLC = Extensive‑stage small cell lung cancer.

Revision History

2025-09-01revisedLatest

Clarified reauthorization criteria and updated references; Separated Cosela (MBO agent) from Kinase Inhibitor policy and aligned criteria with MassHealth for HOPA implementation. Effective 9/1/25.

2023-02-01clarified

Clarified Cosela reauthorization approval duration to 3 months (historical note). Effective 2/1/23.