Pharmacy Prior Authorization Criteria

Imdelltra (tarlatamab-dlle)

Indications for Prior Authorization

Imdelltra (tarlatamab-dlle)

• For diagnosis of Small cell lung cancer (SCLC)
  Indicated for the treatment of adult patients with extensive stage small cell lung cancer (ES-SCLC) with disease progression on or after platinum-based chemotherapy.

Criteria

Imdelltra

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)

• Diagnosis of extensive stage small cell lung cancer (ES-SCLC)
AND
• Disease has progressed on or after platinum-based chemotherapy (e.g., cisplatin, carboplatin)
AND
• Patient has an Eastern Cooperative Oncology Group (ECOG) Score of 0 or 1

Imdelltra

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2025-12-03, 2025-07-02, 2024-07-02

References

1. Imdelltra Prescribing Information. Amgen Inc. Thousand Oaks, CA. November 2025.

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Revision History

• 2025-12-03: Background updates
• 2025-07-02: 2025 Annual Review - no changes
• 2024-07-02: New Program

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