Medical Policy

Effective Date:01/01/2014 Title:Gilotrif (Afatinib)
Revision Date:06/01/2019 Document:BI442:00
CPT Code(s):
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Gilotrif requires prior authorization.

2)    Gilotrif is used to treat certain types of non-small cell lung cancer (NSCLC).

3)    Gilotrif is covered under the pharmacy benefit as a specialty drug and must be obtained through the contracted specialty pharmacy.

Medical Statement

1)    Gilotrif requires prior authorization.

2)    Gilotrif is considered medically necessary as treatment of patients with metastatic or recurrent non-small cell lung cancer with one of the following:

a)    Tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations as detected by an FDA-approved test, OR

b)    Disease is squamous and has progressed after platinum-based chemotherapy (e.g. cisplatin,carboplatin)

Limits

Gilotrif must be obtained through the contracted specialty pharmacy.

Reference

1)    Gilotrif Package Insert. Boehringer Ingelheim Pharmaceuticals, Inc. Janurary 2018.

2)    Clinical Pharmacology. Gilotrif – accessed online 04-25-2019.

3)     NCCN Drugs and Biologics Compendium. Accessed online 04-25-2019

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.