Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Trilaciclib (Cosela) may be considered medically necessary for individuals 18 years of age or older when the following criteria are met:
Food and Drug Administration Indications
- Individual diagnosed with extensive-stage small cell lung cancer (ES-SCLC); and
- Platinum/etoposide-containing regimen or topotecan containing regimen is planned; and
- Trilaciclib (Cosela) will be used to decrease the incidence of chemotherapy-induced myelosuppression; or
National Comprehensive Cancer Network Recommendations
Management of Cancer and Chemotherapy Induced Anemia
- When used as a prophylactic option to decrease the incidence of chemotherapy-induced myelosuppression when administered before platinum/etoposide with or without immune checkpoint inhibitor-containing regimens or a topotecan-containing regimen for ES-SCLC; or
Management of Neutropenia
- When used as a prophylactic option to decrease the incidence of chemotherapy-induced myelosuppression when administered before platinum/etoposide with or without immune checkpoint inhibitor-containing regimens or a topotecan-containing regimen for ES-SCLC in the curative/adjuvant or palliative setting, or as a secondary prophylaxis.
Trilaciclib (Cosela) for any other indication is considered experimental and investigational. Scientific evidence does not support its use for any other indication.
Procedure Codes
