COVERED USES:

FDA Approved Indications:

Maintenance treatment of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) whose disease has not progressed after four cycles of platinum-based first-line chemotherapy.

Locally advanced or metastatic non-small cell lung cancer after failure of at least one prior chemotherapy regimen.

Approved as a first-line agent in combination with gemcitabine for advanced, inoperable, or metastatic pancreatic cancer.

All FDA-approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

Must be prescribed by an Oncologist.

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

Tarceva® will be approved, subject to benefits, for patients who meet the following:

• Maintenance treatment of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) whose disease has not progressed after four cycles of platinum-based first-line chemotherapy.
• Locally advanced or metastatic non-small cell lung cancer after failure of at least one prior chemotherapy regimen (162._)
• Approved as a first line agent in combination with gemcitabine for advanced, inoperable, or metastatic Pancreatic cancer (157._)

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to six months.