Western Health Advantage
Vitrakvi (larotrectinib)
Drugs for Cancer : Drugs for Cancer
  • Chronic Lymphocytic Leukemia:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Drug Policy Based On: NCCN Guidelines
    Concomitant Therapy Requirement: 1 of Acalabrutinib;bendamustine;chlorambucil;Venetoclax
    Diagnosis Types: 1 of as a single agent for relapsed/refractory without 17p deletion;CLL with or without 17p deletion;first line in combination with chlorambucil for disease without deletion 17p/TP53 mutation;first line, as a single agent;Previously untreated CLL;Small Lymphocytic Lymphoma

    Follicular Lymphoma (FL), Non Hodgkin Lymphoma (NHL):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • Nasal Polyposis:
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • Prior Authorization: Acute Migraine:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Prior Authorization: PA Required