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.
The use of amivantamab-vmjw (Rybrevant) may be considered medically necessary for individuals 18 years or older when
ALL
of the following criteria are met:
Non-Small Cell Lung Cancer
-
Individual diagnosed with locally advanced or metastatic non- small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 20 insertion mutations;
and
-
Treatment is used as a single agent for disease progression while on or after platinum-based chemotherapy;
or
-
Treatment is used first line or in combination with carboplatin and pemetrexed;
or
Compendia Sources
Amivantamab-vmjw (Rybrevant) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of amivantamab-vmjw (Rybrevant) for any indication not listed on this policy is considered experimental/investigational, and therefore, not covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Code
