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.
Irinotecan liposomal (Onivyde) in combination with fluorouracil and leucovorin, may be considered medically necessary for the treatment of individuals with metastatic adenocarcinoma of the pancreas after disease progression following gemcitabine-based therapy; or
Irinotecan liposomal (Onivyde) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of irinotecan liposomal (Onivyde) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.