Restricted to:

• Service line: Hematology/Oncology
• Formulary location: Outpatient Infusion
• Service location: Outpatient Infusion Center
• Patient population: Adult
• Prior authorization required: Yes
• Restriction/criteria of use (all will apply unless specified):
  • Confirmed unresectable hepatocellular carcinoma (uHCC) and will receive durvalumab in combination with tremelimumab-actl
    • Child-Pugh Score class A
    • ECOG performance status of 0–1
    • No Hepatitis B and Hepatitis C co- infection, or Hepatitis B and Hepatitis D co-infection
    • No hepatic encephalopathy within the past 12 months
    • No GI bleeding within the past 12 months
  • Confirmed untreated metastatic NSCLC and tremelimumab-actl will be part of a regimen including durvalumab and platinum-based chemotherapy regimen.
    • No prior lines of therapy for metastatic NSCLC
    • Absence of EGFR or ALK mutation
    • ECOG performance status of 0–1 
    • Indication identified in the NCCN Guidelines with recommendation as category 1 or 2A only
    •  

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