Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Trilaciclib (Cosela) may be considered medically necessary for individuals 18 years of age or older when the following criteria are met:
- 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.
Compendia Sources
Trilaciclib (Cosela) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of trilaciclib (Cosela) for any other indication than listed above is considered experimental/investigational and therefore, not covered. The safety and/or efficacy cannot be established by review of the available published peer-reviewed literature.
Procedure Code
