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Pemazyre – Criteria (PDF) Criteria-Based Consultation Prescribing Program CRITERIA FOR DRUG COVERAGE Pemigatinib (Pemazyre) Notes: • Quantity Limits: Yes (#14 tablets per 21 days) Initiation (new start) criteria: Non-formulary pemigatinib (Pemazyre) will be covered on the prescription drug benefit when the following criteria are met: • Prescribed by a hematologist or oncologist AND • ECOG 0-1 AND • Age > 18 AND • Diagnosis of unresectable, locally advanced or metastatic cholangiosarcoma AND • Prior treatment with a first-line chemotherapy regimen per National Comprehensive Cancer Network (NCCN) Hepatobiliary Cancers Guideline (e.g. gemcitabine+cisplatin/oxaliplatin, 5- FU/capecitabine+cisplatin/oxaliplatin, gemcitabine+nab-paclitaxel, gemcitabine+capecitabine, gemcitabine+nab-paclitaxel+cisplatin, 5-FU, capecitabine, gemcitabine, pembrolizumab, entrectinib, larotrectinib) per NCCN Biliary Tract Cancers Guidelines AND • Fibroblast growth factor receptor 2 (FGFR2) fusion or rearrangement Criteria for current Kaiser Permanente members already taking the medication who have not been reviewed previously: Non-formulary pemigatinib (Pemazyre) will be covered on the prescription drug benefit when the following criteria are met: kp.org cps/awc Revised 05/13/21 Effective 07/15/21 Criteria-Based Consultation Prescribing Program CRITERIA FOR DRUG COVERAGE Pemigatinib (Pemazyre) • Prescribed by a hematologist or oncologist AND • Age > 18 AND • Diagnosis of unresectable, locally advanced or metastatic cholangiosarcoma AND • Fibroblast growth factor receptor 2 (FGFR2) genetic alteration fusion or rearrangement Criteria for new members entering Kaiser Permanente already taking the medication who have not been reviewed previously. Non-formulary pemigatinib (Pemazyre) will be covered on the prescription drug benefit when the following criteria are met: • Prescribed by a hematologist or oncologist AND • Age > 18 AND • Diagnosis of unresectable, locally advanced or metastatic cholangiosarcoma AND • Fibroblast growth factor receptor 2 (FGFR2) genetic alteration fusion or rearrangement kp.org cps/awc Revised 05/13/21 Effective 07/15/21 .
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