Pharmacy Prior Authorization Criteria

Tevimbra (tislelizumab)

Indications for Prior Authorization

Tevimbra (tislelizumab)

• For diagnosis of Esophageal Squamous Cell Carcinoma
  (1) Indicated for the treatment of adult patients with unresectable or metastatic esophageal squamous cell carcinoma after prior systemic chemotherapy that did not include a PD-(L)1 inhibitor (2) In combination with platinum-containing chemotherapy, indicated for first-line treatment of adults with unresectable or metastatic esophageal squamous cell carcinoma whose tumors express PD-L1 (≥1)

• For diagnosis of Gastric or Gastroesophageal Junction Adenocarcinoma
  Indicated for the first-line treatment of adults with unresectable or metastatic HER2- negative gastric or gastroesophageal junction adenocarcinoma (G/GEJ) whose tumors express PD-L1 (≥1)

Criteria

Tevimbra

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Esophageal Squamous Cell Carcinoma

• Diagnosis of esophageal squamous cell carcinoma
AND
• Disease is one of the following:
• Unresectable
• Metastatic
AND
• One of the following:
• Both of the following:
• Patient has received prior systemic chemotherapy
AND
• Patient has not previously been treated with a PD-(L)1 inhibitor (e.g., Keytruda, Opdivo
OR
• Used in combination with platinum-containing chemotherapy (e.g., carboplatin, cisplatin, oxaliplatin)

Tevimbra

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)
For diagnosis of Gastric or gastroesophageal junction adenocarcinoma

• Diagnosis of gastric or gastroesophageal junction adenocarcinoma
AND
• Disease is one of the following:
• Unresectable
• Metastatic
AND
• Disease is human epidermal growth factor receptor 2 (HER2)-negative
AND
• Tumor(s) express PD-L1 as detected by an FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Used in combination with platinum (e.g., carboplatin, cisplatin, oxaliplatin) and fluoropyrimidine (e.g., fluorouracil) -based chemotherapy

Tevimbra

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of All indications listed above

• Patient does not show evidence of progressive disease while on therapy

P & T Revisions

2025-03-31, 2025-02-05, 2024-09-27, 2024-09-26

References

1. Tevimbra Prescribing Information. BeiGene USA, Inc. San Mateo, CA. March 2025.

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Revision History

• 2025-03-31: Updated criteria for new indication for Esophageal Squamous Cell Carcinoma
• 2025-02-05: Added criteria for new indication of gastric or gastroesophageal junction adenocarcinoma
• 2024-09-27: New Program for Tevimbra
• 2024-09-26: New Program for Tevimbra

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