ALECENSA (alectinib)

Self-Administration – Oral

Indications for Prior Authorization:
  • Non-small cell lung cancer (NSCLC): Indicated for the treatment of patients with anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer (NSCLC) as detected by an FDA-approved test.

Coverage Criteria:

For diagnosis of non-small cell lung cancer (NSCLC):

  • Dose does not exceed 1,200 mg per day, AND

  • Prescribed by or in consultation with an oncologist, AND

  • The patient has metastatic non-small cell lung cancer, AND

  • The patient has anaplastic lymphoma kinase (ALK)-positive disease as detected with an FDA-approved test or test performed at a Clinical Laboratory Improvement Amendments (CLIA)-approved facility*

Reauthorization Criteria:
  • Patient has not experienced disease progression

Coverage Duration: 
  • Initial: 12 months

  • Reauthorization: 12 months

Authorization is not covered for the following:
  • The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 
  • CLIA-certified laboratories: https://wwwn.cdc.gov/clia/Resources/LabSearch.aspx

Policy Updates:
  • 05/16/2023 – Updated indication and coverage criteria, added reauthorization criteria. 

References:
  • Alecensa prescribing information. Genentech. South San Francisco, CA. September 2021.

Last review date: June 1, 2023

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