Xalkori
Defines coverage, prior authorization documentation, and authorization durations for Xalkori (crizotinib) across FDA-approved and NCCN-compendial indications including ALK- or ROS1-positive NSCLC, ALK-positive ALCL, ALK-positive IMT, histiocytic neoplasms, and select melanoma and MET-altered NSCLC indications.
Indications and compendial uses listed with authorization duration of 12 months and required documentation for biomarker status.
Coverage Summary & Scope
Defines coverage for Xalkori (crizotinib) across FDA-approved and NCCN-compendial indications including ALK- or ROS1-positive metastatic NSCLC, ALK-positive ALCL, ALK-positive IMT, histiocytic neoplasms, select cutaneous melanoma and MET-altered NSCLC. Prior authorization is required with submission of relevant biomarker documentation (ALK, ROS1, MET exon 14 skipping, or high-level MET amplification). When approval criteria are met, prior authorization may be granted for 12 months; reauthorization requires absence of unacceptable toxicity (for ALK- and ROS1-NSCLC and other indications) and absence of disease progression (for other indications) as specified.
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