Prior Authorization Form

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TRICARE Prior Authorization Criteria – Mekinist and Tafinlar
Mekinist (trametinib) and Tafinlar (dabrafenib) are oral oncologic agents indicated for metastatic
melanoma.
Prior Authorization Criteria for Mekinist
PA criteria apply to all new users of Mekinist
Manual PA criteria:
Coverage approved for treatment of patients alone or in combination with dabrafenib
(Tafinlar) in patients with unresectable or metastatic melanoma with BRAF V600E or
V600K mutations as detected by an FDA-approved test
Coverage not approved as a single agent in patients who have received prior BRAF-
inhibitor therapy
Prior Authorization Criteria for Tafinlar
PA criteria apply to all new users of Tafinlar
Manual PA criteria:
Coverage approved as a single agent for treatment of patients with unresectable or
metastatic melanoma with BRAF V600E mutation as detected by an FDA-approved test
Combination use with Mekinist in the treatment of patients with unresectable or
metastatic melanoma with BRAF V600E or V600K mutations as detected by an FDA-
approved test
Not approved for patients with wild-type BRAF melanoma
Criteria approved through the DOD P&T Committee process
Criteria approved through the DoD P&T Committee process
is the official Web site of the
Defense Health Agency,
a component of the
Military Health System
DHHQ, 7700 Arlington Blvd,
Falls Church, VA 22042

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