Pharmacy Prior Authorization Criteria

Ensacove (ensartinib)

Indications for Prior Authorization

Ensacove (ensartinib)

• For diagnosis of Non-Small Cell Lung Cancer (NSCLC)
  Indicated for the treatment of adult patients with anaplastic lymphoma kinase (ALK)-positive locally advanced or metastatic non-small cell lung cancer (NSCLC) who have not previously received an ALK-inhibitor [2]

Criteria

Ensacove

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of non-small cell lung cancer (NSCLC)
AND
• Disease is one of the following:
• Locally advanced
• Metastatic
AND
• Disease is anaplastic lymphoma kinase (ALK) rearrangement-positive as detected by an FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Patient has not previously received an ALK-inhibitor [e.g., Alecensa (alectinib), Alunbrig (brigatinib), Lorbrena (lorlatinib), Xalkori (crizotinib), Zykadia (ceritinib)]

Ensacove

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2025-07-09

References

1. Ensacove Prescribing Information. Xcovery Holdings, Inc. Miami, FL. July 2025.
2. The National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium. Available at: http://www.nccn.org/professionals/drug_compendium/content/contents.asp. Accessed July 7, 2025.

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Revision History

• 2025-07-09: New program.

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