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.
Tarlatamab-dlle (Imdelltra) may be considered medically necessary in individuals 18 years and older for the following:
-
Individual is diagnosed with extensive-stage small cell lung cancer (ES-SCLC);
and
-
Individual has disease progression on or after platinum-based chemotherapy;
or
Compendia Sources
Tarlatamab-dlle (Imdelltra) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
Note:
Administration of the step-up dosing schedule should be performed in an appropriate healthcare setting with medical support to manage severe reactions.
The use of tarlatamab-dlle (Imdelltra) 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.
Procedure Codes
