Pharmacy Prior Authorization Criteria

Lorbrena (lorlatinib)

Indications for Prior Authorization

Lorbrena (lorlatinib)

• For diagnosis of Non-small cell lung cancer (NSCLC)
  Indicated for the treatment of adult patients with metastatic non-small cell lung cancer (NSCLC) whose tumors are anaplastic lymphoma kinase (ALK)-positive as detected by an FDA-approved test.

Criteria

Lorbrena

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of non-small cell lung cancer (NSCLC)
AND
• One of the following:
• Patient has had disease progression on, contraindication or intolerance to, or is not a candidate for one of the following:
• Alecensa (alectinib)
• Alunbrig (brugatinib)
OR
• For continuation of prior therapy

Lorbrena

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2025-02-27, 2024-01-23, 2023-07-05, 2023-06-03, 2023-01-04, 2021-12-14, 2021-04-14, 2020-12-07, 2019-12-03

References

1. Lorbrena Prescribing Information. Pfizer Labs. New York, NY. August 2024.

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Revision History

• 2025-02-27: 2025 Annual Review - No criteria changes
• 2024-01-23: 2024 Annual Review - No changes to criteria
• 2023-07-05: update guideline
• 2023-06-03: Program update to remove criterion that confirms ALK tumor status.
• 2023-01-04: 2023 Annual Review: no changes to clinical criteria
• 2021-12-14: 2022 Annual Review: no changes to clinical criteria
• 2021-04-14: Modified PA per new FDA approved indication. Added embedded ST. Updated background and references. Updated GPIs due to GPI replication.
• 2020-12-07: 2021 Annual Review: updated reauth criteria
• 2019-12-03: 2020 Annual Review; no changes

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