Ramucirumab (Cyramza®) is a recombinant human IgG1 monoclonal antibody that blocks the binding of vascular endothelial growth factor (VEGF) receptor 2 to VEGFR ligands (VEGF-A, VEGF-C, and VEGF-D). By attaching itself to the VEGF receptor 2 of cancer cells, ramucirumab (Cyramza) is able to prevent the receptor from being activated, thus inhibiting proliferation and migration of the cells, and inhibiting angiogenesis.
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:
Food and Drug Administration (FDA) Indications
Colorectal Cancer
Gastric Cancer
Hepatocellular Carcinoma
Lung Cancer, Non-Small Cell (NSCLC)
National Comprehensive Cancer Network (NCCN) Recommendations
Colon Cancer
Esophageal and Esophagogastric Junction Cancers
Gastric Cancer
Hepatocellular Carcinoma
Lung Cancer, Non-Small Cell (NSCLC)
Rectal Cancer
Ramucirumab (Cyramza) is considered experimental/investigational for all other indications. Scientific evidence does not support the use of ramucirumab (Cyramza) for any other indications not listed above.
J9308 |
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.
C15.3 | C15.4 | C15.5 | C15.8 | C15.9 | C16.0 | C16.1 |
C16.2 | C16.3 | C16.4 | C16.5 | C16.6 | C16.8 | C16.9 |
C17.0 | C17.1 | C17.2 | C17.8 | C17.9 | C18.0 | C18.1 |
C18.2 | C18.3 | C18.4 | C18.5 | C18.6 | C18.7 | C18.8 |
C18.9 | C19 | C20 | C21.8 | C22.0 | C22.8 | C22.9 |
C33 | 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 | C78.00 | C78.01 | C78.02 | C78.6 |
C78.7 | D37.1 | D37.2 | D37.3 | D37.4 | D37.5 | D37.8 |
D37.9 | Z85.00 | Z85.01 | Z85.028 | Z85.038 | Z85.068 | Z85.118 |
NA
1-22-2020 added additional NCCN indications and formatting changes, updated FDA statement, added additional diagnosis, updated references [this info is also for Ramucirumab (Cyramza)]