Olaratumab (Lartruvo)

Section: Injections
Effective Date: February 01, 2020
Revised Date: January 27, 2020
Last Reviewed: January 22, 2020

Description

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.

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.

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:

  • Individual is 18 years of age or older; and
  • Individual has been receiving therapy with olaratumab (Lartruvo); and
  • There has been a proven clinical benefit with olaratumab (Lartruvo); and
  • Individual is enrolled in the Lartruvo Patient Access Program; and
  • Individual is being treated for ANY ONE of the following indications:

Soft Tissue Sarcoma (STS) – Angiosarcoma

  • In combination with doxorubicin in individuals with STS with a histologic subtype for which an anthracycline-containing regimen is appropriate and which is not amenable to curative treatment with radiotherapy or surgery; or

Soft Tissue Sarcoma – Retroperitoneal/Intra-abdominal

  • In combination with doxorubicin for:
    • preoperative chemotherapy for resectable disease; or
    • primary chemotherapy or chemoradiation for attempted downstaging of unresectable, recurrent, or metastatic disease; or
    • Palliative therapy for unresectable or progressive disease; or

Soft Tissue Sarcoma – Rhabdomyosarcoma

  • Therapy for pleomorphic rhabdomyosarcoma in combination with doxorubicin; or

Soft Tissue Sarcoma of the Extremity/Superficial Trunk, Head/Neck

  • In combination with doxorubicin for:
    • Preoperative chemotherapy or chemoradiation for resectable stage III tumors (primary tumors or local recurrence) with acceptable functional outcomes; or
    • Primary treatment as chemotherapy or chemoradiation for stage II-III resectable disease with adverse functional outcomes or unresectable disease (primary tumors or local recurrence); or
    • Adjuvant chemotherapy for resectable stage III disease (primary tumors or local recurrence) with acceptable functional outcomes; or
    • Adjuvant chemotherapy for resectable stage II-III disease with acceptable functional outcomes following primary treatment for resectable stage II-III disease with adverse functional outcomes; or
    • Treatment before or after metastasectomy for single-organ confined, limited tumor bulk synchronous stage IV or recurrent disease that is amenable to local therapy or for recurrent isolated regional disease that is amenable to local therapy or for recurrent isolated regional disease or isolated regional lymph nodes; or 
    • Treatment in addition to stereotactic body radiation therapy (SBRT) for single-organ confined, limited tumor bulk stage IV or recurrent disease that is amenable to local therapy or for recurrent isolated regional disease or isolated regional lymph nodes; or
    • Chemotherapy following regional node dissection for metastatic disease; or
    • Palliative chemotherapy for stage IV or recurrent disease with disseminated metastases for which an anthracycline-containing regimen is appropriate

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.

Procedure Codes

J9285

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.

Diagnosis Codes

Covered Diagnosis Codes

C47.0 C47.10 C47.11 C47.12 C47.20 C47.21 C47.22
C47.3 C47.4 C47.5 C47.6 C47.8 C47.9 C48.0
C48.1 C48.2 C48.8 C49.0 C49.10 C49.11 C49.12
C49.20 C49.21 C49.22 C49.3 C49.4 C49.5 C49.6
C49.8 C49.9 C78.00 C78.01 C78.02 Z85.831

Professional Statements and Societal Positions Guidelines

NA

Links