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.
Lurbinectedin (Zepzelca) may be considered medically necessary in individuals 18 years and older for the following:
Food and Drug Administration (FDA) Indications
Small Cell Lung Cancer (SCLC)
- As treatment of individuals with metastatic SCLC with disease progression on or after platinum-based chemotherapy; or
National Comprehensive Cancer Network (NCCN) Recommendations
Small Cell Lung Cancer (SCLC)
- As subsequent systemic therapy for individuals with performance status 0-2 as a single agent in ANY of the following:
- For relapse within 6 months following complete or partial response or stable disease with initial treatment; or
- For relapsing occurring more than 6 months following complete or partial response or stable disease with initial treatment; or
- For primary progressive disease.
Lurbinectedin (Zepzelca) for any other indication is considered experimental/investigational and therefore non-covered. Scientific evidence does not support its use for any other indication.
Procedure Codes
