Olaratumab (LartruvoTM) is a platelet-derived growth factor (PDGF) receptor-alpha blocking antibody. When PDGF receptors are stimulated they cause tumor growth. Olaratumab (Lartruvo) blocks these receptors, which may help slow or stop tumor growth.
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.
Olaratumab (Lartruvo) for individuals initiating new therapy is considered experimental and investigational and, therefore, not covered.
Olaratumab (Lartruvo) may be considered medically necessary for individuals who meet ALL of the following criteria:
Soft Tissue Sarcoma (STS) – Angiosarcoma
Soft Tissue Sarcoma – Retroperitoneal/Intra-abdominal
Soft Tissue Sarcoma – Rhabdomyosarcoma
Soft Tissue Sarcoma of the Extremity/Superficial Trunk, Head/Neck
The use of olaratumab (Lartruvo) for any other indication is considered experimental/investigational and therefore, not covered. Scientific evidence does not support its use for any other indications.
Note: All individuals must be enrolled in the Lartruvo Patient Access Program (PAP). Participation in the PAP will be the only way an individual may remain on therapy after Lartruvo has been withdrawn from the market.
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. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
Covered Diagnosis Codes
Professional Statements and Societal Positions Guidelines