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:
Food and Drug Administration (FDA) Indications
Non-Small Cell Lung Cancer
- Individual diagnosed with locally advanced or metastatic non- small cell lung cancer (NSCLC); and
- Individual has epidermal growth factor receptor (EGFR) exon 20 insertion mutations; and
- Disease has progressed while on or after platinum-based chemotherapy; or
National Comprehensive Cancer Network (NCCN) Recommendations
Non-Small Cell Lung Cancer
- As subsequent therapy as a single agent for EGFR exon 20 insertion mutation positive recurrent, advanced, or metastatic disease for individuals with performance status 0-2
The use of Amivantamab-vmjw (Rybrevant) for any indication not listed on this policy is considered experimental/investigational, and therefore, not covered. Scientific evidence does not support the use of Amivantamab-vmjw (Rybrevant) for any other indications.
Procedure Codes