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Necitumumab (Portrazza)

Section: Injections
Effective Date: October 01, 2019
Revised Date: September 30, 2019

Description   

Necitumumab (Portrazza™) is a recombinant human IgG1 monoclonal antibody that binds to the human epidermal growth factor receptor (EGFR) and blocks the binding of EGFR to its ligands. Expression and activation of EGFR has been correlated with malignant progression, induction of angiogenesis and inhibition of apoptosis.

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.

Necitumumab (Portrazza) may be considered medically necessary in combination with gemcitabine and cisplatin medically necessary as first-line treatment of individuals 18 years of age or older with metastatic squamous non-small cell lung cancer (NSCLC).

Necitumumab (Portrazza) is considered experimental/investigational for any other indication and therefore, non-covered.  Scientific evidence does not support its use for any other indications.

Procedure Codes

J9295

Note: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Highmark may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.

Diagnosis Codes

C34.00 C34.01 C34.02 C34.10 C34.11 C34.12 C34.2
C34.30 C34.31 C34.32 C34.80 C34.81 C34.82 C34.90
C34.91 C34.92

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