Vizimpro®

Drug - Vizimpro® (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

OR

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

Questions?

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