osimertinib (Tagrisso®)


Indications for Prior Authorization:

  • Non-small cell lung cancer, metastatic

All of the following must be met as a condition for coverage:

  • Treatment of metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive non-small cell lung cancer (NSCLC), as detected by an FDA-approved test, in patients who have progressed on or after EGFR tyrosine kinase inhibitor (TKI) therapy

This Medication is Not Approvable for the following condition(s):

  • Any condition not listed above as an approved indication

Dosing and Duration of Therapy

  • Non-small cell lung cancer, metastatic (T790M EGFR mutation-positive):
    • Usual dosage:   80 mg once daily until disease progression or unacceptable toxicity


One year


Last review date: July 25, 2016