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.
Tebentafusp-tebn (Kimmtrak) may be considered medically necessary for individuals 18 years of age or older for the following:
Uveal Melanoma
- Treatment of individuals with HLA-A*02:01-positive, unresectable or metastatic uveal melanoma; or
Compendia Sources
Tebentafusp-tebn (Kimmtrak) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of tebentafusp-tebn (Kimmtrak) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Codes
