Medical Policy

Effective Date:07/01/2016 Title:Alecensa (Alectinib)
Revision Date:11/01/2019 Document:BI501:00
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)    Alecensa (Alectinib) requires prior authorization.

2)    Alecensa is used to treat a specific type of lung cancer.

3)    Alecensa is considered a specialty drug, covered under the pharmacy benefit, and must be obtained through a contracted specialty pharmacy.

Medical Statement

Alecensa (Alectinib) is considered medically necessary for members meeting the following conditions:

1)    Diagnosis of metastatic non-small cell lung cancer (NSCLC) that is ALK-positive (as detected by an FDA approved test) 

a.    as first-line therapy OR

b.    after progression on or patient intolerant to Xalkori (crizotinib) AND

2)    Contraceptive counseling has been provided


As a specialty drug, Alecensa is limited to no more than a 30 day supply per fill.

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Application to Products

This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, 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.