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Coverage criteria policies

Ipilimumab (Yervoy®)

These services may or may not be covered by your HealthPartners plans. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Ipilimumab requires prior authorization from Pharmacy Administration.

Coverage

Ipilimumab (Yervoy) is considered medically necessary when used for treatment of unresectable or metastatic melanoma in patients 12 years and older when prescribed using the FDA-approved regimen of 3 mg/kg every 3 weeks for a total of 4 doses all given within a 16-week period.

Requests for retreatment will be reviewed on a case by case basis.

Ipilimumab (Yervoy) is considered medically necessary when used for adjuvant treatment of patients with cutaneous melanoma with pathologic involvement of regional lymph nodes of more than 1 mm who have undergone complete resection, including total lymphadenectomy, after the failure of nivolumab (Opdivo) and when prescribed using the FDA-approved regimen of 10mg/kg every 3 weeks x 4 doses, then quarterly. Nivolumab (Opdivo) requires prior authorization from Pharmacy Administration.

Initial approvals will be for six months. Reauthorizations will be approved annually thereafter while there is no progression of disease.

Definitions

Melanoma is a cancer of skin cells or melanocytes.

Ipilimumab (Yervoy) is a human cytotoxic T-lymphocyte antigen 4 (CTLA-4)-blocking antibody indicated for:

  • Treatment of unresectable or metastatic melanoma in adults and pediatric patients (12 years and older).
  • Adjuvant treatment of patients with cutaneous melanoma with pathologic involvement of regional lymph nodes of more than 1 mm who have undergone complete resection, including total lymphadenectomy.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS Code

Code

Description

J9228

Injection, ipilimumab, 1 mg

NDC Codes

Codes

Description

00003232711

Yervoy 50 mg/10mL single use solution

00003232822

Yervoy 200 mg/40mL single use solution

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Yervoy Prescribing Information. Princeton, NJ: Bristol-Myers Squibb Company. February 2018.

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Policy activity

  • 09/08/2011 - Date of origin
  • 04/28/2017 - Effective date
Review date
  • 02/2018
Revision date
  • 05/16/2016

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