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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 (Yervoy) requires prior authorization from HealthPartners Pharmacy Administration.

Coverage

Yervoy is generally covered subject to the indications listed below when all of the following criteria are met, and per member plan documents:

  1. Treatment of unresectable or metastatic melanoma in patients 12 years and older; or,
  2. 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, (nivolumab requires prior authorization from Pharmacy Administration); or,
  3. Treatment of patients with previously untreated advanced renal cell carcinoma, in combination with nivolumab; and,
  4. Prescribed within FDA approved dosing regimen; and,
  5. When consulting oncologists indicate that the requested drug and regimen is the most appropriate and most cost-effective therapy option. Consulting oncologists will ensure that acceptable, peer-reviewed literature supports a particular use of an oncology drug. The consulting oncologists are independent, external board-certified medical oncologists and hematologists who work with the health plan and providers to ensure that patients receive the most effective, affordable, and least toxic cancer care possible.

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.
  • Treatment of patients with intermediate or poor risk, previously untreated advanced renal cell carcinoma, in combination with nivolumab.
  • Treatment of adult and pediatric patients 12 years of age and older with microsatellite
  • instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan, in combination with nivolumab. This indication is approved under accelerated approval based on overall response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

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 SOLN

00003232822

Yervoy 200 MG/40ML SOLN

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. July 2018.

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Policy activity

  • 09/08/2011 - Date of origin
  • 04/01/2019 - Effective date
Review date
  • 02/2019
Revision date
  • 02/04/2019

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