Pharmacy Prior Authorization Criteria

Jideytro (zidesamtinib) - PA, NF

Indications for Prior Authorization

Jideytro (zidesamtinib)

• For diagnosis of Non-small Cell Lung Cancer
  Indicated for the treatment of adult patients with locally advanced or metastatic ROS1-positive non-small cell lung cancer (NSCLC) who received a prior ROS1 kinase inhibitor.

Criteria

Jideytro

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of non-small cell lung cancer
AND
• Disease is one of the following:
• Locally advanced
• Metastatic
AND
• Presence of ROS1 rearrangement positive tumor(s) as detected by a FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Patient has received prior treatment with a ROS1 kinase inhibitor (e.g., Augtyro, Xalkori, Rozlytrek)

Jideytro

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

Jideytro

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of non-small cell lung cancer
AND
• Submission of medical records (e.g., chart notes) confirming disease is one of the following:
• Locally advanced
• Metastatic
AND
• Both of the following:
• Submission of medical records (e.g., chart notes) confirming presence of ROS1 rearrangement positive tumor(s)
AND
• Provider attests that rearrangement positive tumor(s) was detected by a FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming patient has received prior treatment with a ROS1 kinase inhibitor (e.g., Augtyro, Xalkori, Rozlytrek)

P & T Revisions

1970-01-01, 2026-09-08

References

1. Prescribing Information Jideytro GSK, July 2026
2. A Study of Zidesamtinib (NVL-520) in Patients With Advanced NSCLC and Other Solid Tumors Harboring ROS1 Rearrangement (ARROS-1) NCT05118789

---

Revision History

• 2026-09-08: New program for Jideytro

---