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.
Mirvetuximab soravtansine-gynx (Elahere) may be considered medically necessary in individuals 18 years and older when ALL of the following criteria are met:
Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer
- Individual has a diagnosis of FR positive, platinum resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer confirmed by an FDA-approved test; and
- Individual has received one (1) to three (3) prior systemic treatment regimens; and
- Individual has received an ophthalmic exam including visual acuity and slit lamp testing prior to treatment; and
- Individual will receive subsequent ophthalmic exams prior to every other cycle for the first eight (8) cycles of treatment.
- Mirvetuximab soravtansine-gynx (Elahere) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of mirvetuximab soravtansine-gynx (Elahere) 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.