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DrugVizimpro® (dacomitinib) [Pfizer Inc.]

June 2019

Therapeutic area - Oncology, Oral – Lung Cancer

Initial approval criteria

  • Patient has a diagnosis that is listed on the FDA-approved label 


  • Patient is at least 18 years old AND
  • Patient has a diagnosis of metastatic non-small cell lung cancer AND
  • Patient’s tumor has EGFR exon 19 deletions or exon 21 (L858R) substitution mutations as confirmed by a FDA-approved test AND
  • Vizimpro will be used as a single-agent first-line therapy AND
  • Patient does not have metastases to the central nervous system (CNS) or leptomeninges
  • Initial approval is for 6 months

Renewal criteria

  • Patient continues to meet the above criteria AND
  • Patient has documented tumor response with stabilization of disease or decrease in size of tumor or tumor spread AND
  • Patient has absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: interstitial lung disease, severe/persistent diarrhea, and exfoliative skin disorders, etc.
  • Renewal approval is for 6 months

Quantity limits

  • 34 tablets/34 days


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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