Durvalumab IV (Infinzi)

OFFICE ADMINISTRATION

Indications for Prior Authorization:

  • Treatment of patients with locally advanced or metastatic urothelial carcinoma who:
    • have disease progression during or following platium-containing chemotherapy
    • have disease progression within 12 months of neoadjuvant or adjuvant treatment with platium-containing chemotherapy

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

  • Prescribed by an oncologist, AND
  • 18 years or older, AND
  • Confirmed diagnosis of advanced/metastatic urothelial carcinoma in patients who failed platium-containing chemotherapy or have disease progression within 12 months of neoadjuvant/adjuvant treatment with platium-containing chemotherapy, AND
  • Patient is unable to take or has failed Keytruda

Dosing:

  • 10 mg/kg IV infusion over 60 minutes every 2 weeks

Approval:

  • Initial: 6 months
  • Renewal: 1 year

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