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APPROVED DRAFT PA Criteria Initial Approval Date: July 11, 2018 Revised Dates: January 20, 2021, October 14, 2020, October 10, 2018

CRITERIA FOR PRIOR AUTHORIZATION OncologyChemotherapy Agents

BILLING CODE TYPE For drug coverage and provider type information, see the KMAP Reference Codes webpage.

MANUAL GUIDELINES Prior authorization will be required for all current and future dose forms available. All medication-specific criteria will be reviewed according to the criteria below.

Brand Name Generic Name Brand Name Generic Name Adcetris () Ibrance () Afinitor () Iclusig ( hcl) Alecensa ( hcl) Idhifa () Alunbrig () Imbruvica () Arranon (nelarabine) Imfinzi () Avastin () Inlyta () Ayvakit () Ixempra (ixabepilone) Balversa () Jakafi ( phosphate) Bavencio () Jevtana (cabazitaxel) Belrapzo (bendamustine) Kadcyla (ado-) Bicnu (carmustine) Kanjinti (trastuzumab) Blincyto () Keytruda () Bosulif () Kisqali () Braftovi () Kisqali Femara (ribociclib-letrozole) Brukinsa () Kyprolis (carfilzomib) Cabometyx () Lartruvo () Calquence () Lenvima () Cotellic () Lonsurf (trifluridine-tipiracil) Cyramza () Lorbrena () Darzalex () Lynparza (olaparib) Darzalex Faspro (daratumumab and Matulane (procarbazine) hyaluronidase) Mekinist () Empliciti () Mektovi () Erbitux () Mozobil (plerixafor) Erivedge () Nerlynx ( maleate) Erleada (apalutamide) Nexavar ( tosylate) Erwinaze (asparaginase erwinia Ninlaro (ixazomib) chrysanthemi) Ogivri (trastuzumab) Farydak (panobinostat) Oncaspar (pegaspargase) Gavreto () Onivyde (irinotecan liposome) Gazyva () Ontruzant (trastuzumab) Gilotrif () Opdivo () Gleevec ( mesylate) Padcev () Herceptin (trastuzumab) Perjeta () Herceptin Hylecta (trastuzumab and Phesgo Pertuzumab, trastuzumab hyaluronidase-oysk) and hyaluronidase-zzxf) Herzuma (trastuzumab) Piqray (alpelisib) Page 1 of 2

Brand Name Generic Name Brand Name Generic Name Polivy (- Trazimera (trastuzumab) piiq) Trelstar (triptorelin) Pomalyst (pomalidomide) Trodelvy () Provenge (sipuleucel-Tt) Truxima () Revlimid (lenalidomide) Tukysa () Riabni (rituximab) Tykerb ( ditosylate) Rituxan (rituximab) Valstar (valrubicin) Rituxan Hycela (rituximab and Vectibix (panitumumab) hyaluronidase human) Venclexta () Rozlytrek () Verzenio () Rubraca (rucaparib)D Vitrakvi () Ruxience (rituximab) Votrient ( hcl) Rydapt () Xalkori () Sandostatin Lar (octreotide) Xofigo (radium Ra 223 dichloride) Somatuline Depot (lanreotide) Xospata ( fumarate) Sprycel () Xtandi (enzalutamide) Stivarga () Yervoy () Sutent ( malate) Yonsa (abiraterone acetate) Tabrecta () Zejula (niraparib) Tafinlar () Zelboraf () Tagrisso () Zirabev (bevacizumab-bvzr) Talzenna (talazoparib tosylate) Zolinza (vorinostat) Tarceva () Zydelig (idelalisib) Tasigna ( hcl) Zykadia () Tecentriq () Zytiga (abiraterone acetate) Tibsovo ()

CRITERIA FOR INITIAL APPROVAL FOR ALL PRODUCTS (MUST MEET ALL OF THE FOLLOWING): • Medication requested must be prescribed according to the FDA-approved indication, age, dose, and pre-requisite treatments located in the package insert.

CRITERIA FOR RENEWAL FOR ALL PRODUCTS: • Prescriber must attest that the patient has experienced a positive clinical response from continuous treatment with the requested medication and is able to tolerate therapy. • Patient must continue to meet the criteria required for initial approval.

LENGTH OF APPROVAL: 12 MONTHS

FOR DRUGS THAT HAVE A CURRENT PA REQUIREMENT, BUT NOT FOR THE NEWLY APPROVED INDICATIONS, FOR OTHER FDA- APPROVED INDICATIONS, AND FOR CHANGES TO AGE REQUIREMENTS NOT LISTED WITHIN THE PA CRITERIA: • THE PA REQUEST WILL BE REVIEWED BASED UPON THE FOLLOWING PACKAGE INSERT INFORMATION: INDICATION, AGE, DOSE, AND ANY PRE-REQUISITE TREATMENT REQUIREMENTS FOR THAT INDICATION.

______DRUG UTILIZATION REVIEW COMMITTEE CHAIR PHARMACY PROGRAM MANAGER DIVISION OF HEALTH CARE FINANCE KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT

______DATE DATE

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