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.
Tremelimumab (Imjudo) may be considered medically necessary for ANY of the following conditions:
Hepatocellular Carcinoma (HCC)
- In combination with durvalumab, for the treatment of adult individuals 18 years of age or older with unresectable HCC; or
Non-Small Cell Lung Cancer (NSCLC)
- In combination with durvalumab and platinum-based chemotherapy, for the treatment of adult individuals 18 years of age or older with metastatic NSCLC with no sensitizing EGFR or ALK mutations; or
Tremelimumab (Imjudo) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of tremelimumab (Imjudo) 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.