The following formulary medications are included in this program (formulary specific):

MAPD formularies: Kanjinti, Mvasi, Ontruzant, Trazimera, Zirabev

HC Enhanced formulary: Ontruzant

PA applies to new starts only

Prior Authorization Criteria for Approval

The requested formulary medication will be approved when BOTH of the following are met:

1. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication
   AND
2. ONE of the following:
   1. There is evidence of a claim that the patient has been treated with the requested medication within the past 180 days
      OR
   2. The prescriber states the patient is currently being treated with the requested medication
      OR
   3. ALL of the following:
      1. Genetic testing has been completed, if required, for therapy with the requested medication and results indicate the requested medication is appropriate
         AND
      2. ONE of the following:
         1. The requested medication is FDA labeled or supported by CMS approved compendia as first-line therapy for the requested indication
            OR
         2. The patient has tried appropriate FDA labeled or CMS approved compendia supported therapy that are indicated as first-line therapy for the requested indication
            OR
         3. The patient has an intolerance or hypersensitivity to the first-line therapy for the requested indication
            OR
         4. The patient has an FDA labeled contraindication to the first-line therapy for the requested indication
            AND
      3. The patient does NOT have any FDA labeled contraindications to the requested medication
         AND
      4. The patient does NOT have any FDA labeled limitations of use that is not otherwise supported in NCCN guidelines

Length of Approval: 12 months