Quantity Limitations
Quantity limitations apply to brand and associated generic products.
Commercial Utilization Management Policy
Version Date: February 2023
Restricted Product(s)
- Gavreto™ (pralsetinib)
FDA Approved Use
- For the treatment of adult patients with metastatic rearranged during transfection (RET) fusion-positive non-small cell lung cancer as detected by an FDA approved test (NSCLC).
- For the treatment of adult and pediatric patients 12 years and older with advanced or metastatic RET-mutant medullary thyroid cancer (MTC) who require systemic therapy.
- For the treatment of adult and pediatric patients 12 years and older with advanced or metastatic RET fusion-positive thyroid cancer who require systemic therapy and who are radioactive iodine-refractory (if radioactive iodine is appropriate).
Criteria for Approval of Restricted Product(s)
- The patient is currently taking the requested medication for a cancer diagnosis; AND
- The patient will utilize the generic formulation of this product (if available); OR
- The patient has a diagnosis of metastatic non-small cell lung cancer (NSCLC); AND
- The patient is 18 years of age or older; AND
- The patient is RET fusion-positive (medical record documentation required); OR
- The patient has a diagnosis of advanced or metastatic medullary thyroid cancer; AND
- The patient is 12 years of age or older; AND
- The patient requires systemic therapy; AND
- The patient is RET-mutation positive (medical record documentation required); OR
- The patient has a diagnosis of advanced or metastatic thyroid cancer; AND
- The patient is 12 years of age or older; AND
- The patient requires systemic therapy; AND
- The patient is RET fusion-positive (medical record documentation required); AND
- The patient is being managed by or in consultation with an oncologist; AND
- Indications outside of FDA labeling will be subject to medical necessity review in accordance with specific strong endorsement or support by nationally recognized compendia, when such recommendation is based on strong/high levels of evidence, and/or uniform consensus of clinical appropriateness has been reached. [Medical records and references / evidence must be provided]; AND
- For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.
Duration of Approval: 365 days (1 year)
| Medication | Quantity per Day (unless specified) |
|---|---|
| Gavreto (pralsetinib) 100 mg capsule | 4 capsules |
Quantity Limit Exception Criteria
- The quantity (dose) requested is for documented titration purposes at the initiation of therapy (authorization for a 90 day titration period); AND
- The prescribed dose cannot be achieved using a lesser quantity of a higher strength; AND
- The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR
- If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed).
Duration of Approval: 365 days (1 year)
References
All information referenced is from FDA package insert unless otherwise noted below.
Policy Implementation/Update Information
February 2023: Criteria update: Criteria review and formatting changes. Added duration of approval to the quantity limit exception criteria.
December 2020: Criteria update: Addition of expanded indication for RET-Mutant medullary thyroid cancer and RET fusion-positive thyroid cancer.
September 2020: Original utilization management criteria issued.
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