Dacomitinib (Vizimpro®)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • Indicated for the first-line treatment of patients with metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 19 deletion or exon 21 L858R substitution mutations as detected by an FDA-approved test

Patients must meet the following criteria for the indication(s) above:

  • Patient has a diagnosis of metastatic NSCLC, AND
  • Patient has EGFR exon 19 deletion or exon 21 L858R substitution mutation as detected by an FDA-approved test, AND
  • Prescribed by an oncologist, AND
  • Vizimpro® will not be used in combination with proton pump inhibitors (PPIs)

Dosing:

  • 45mg once daily

Approval:

  • 1 year

Last review date: September 3, 2019

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