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:
Small Cell Lung Cancer (SCLC)
-
As treatment of individuals with metastatic SCLC with disease progression on or after platinum-based chemotherapy;
or
Compendia Sources
Lurbinectedin (Zepzelca) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of lurbinectedin (Zepzelca) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
