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.
Ramucirumab (Cyramza) may be considered medically necessary for
ANY
of the following indications:
Colorectal Cancer
-
In combination with irinotecan, folinic acid, and fluorouracil (FOLFIRI) for the treatment of individuals with metastatic colorectal cancer (mCRC) with disease progression on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine;
or
Gastric Cancer
-
As a single agent or in combination with paclitaxel for individuals with advanced or metastatic, gastric or gastro-esophageal junction adenocarcinoma with disease progression on or after prior fluoropyrimidine- or platinum-containing chemotherapy;
or
Hepatocellular Carcinoma
-
As single agent therapy for the treatment of individuals with HCC who have an alpha fetoprotein (AFP) of 400 ng/mL or greater and have been treated with sorafenib;
or
Lung Cancer, Non-Small Cell (NSCLC)
-
In combination with erlotinib, for first-line treatment of metastatic NSCLC with epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) mutations;
or
-
In combination with docetaxel as treatment of individuals with metastatic NSCLC with disease progression on or after platinum-based therapy:
-
Individuals with EGFR or anaplastic lymphoma kinase (ALK) genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving ramucirumab (Cyramza);
or
Compendia Sources
Ramucirumab (Cyramza) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of ramucirumab (Cyramza) 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.
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