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HealthPartners

Coverage criteria policies

Necitumumab (Portrazza®)

These services may or may not be covered by your HealthPartners plan. 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

Portrazza® requires prior authorization for use from Pharmacy Administration.

Coverage

Necitumumab is generally covered for (1) first-line treatment of patients with metastatic squamous non-small cell lung cancer (NSCLC) and (2) when used in combination with gemcitabine and cisplatin and (3) when used according to the FDA-approved regime of 800 mg intravenous (IV) infusion over 60 minutes on Days 1 and 8 of each 3-week cycle and (4) with documentation of a risk/benefit discussion and medical necessity statement for the addition of necitumumab.

Initial approvals will be provided for six months. Renewals will be provided annually with documentation that the medication is effective.

Definitions

Portrazza is an epidermal growth factor receptor (EGFR) antagonist indicated, in combination with gemcitabine and cisplatin, for first-line treatment of patients with metastatic squamous non-small cell lung cancer.

Limitation of Use: Portrazza is not indicated for treatment of non-squamous non-small cell lung cancer.

If available, codes 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

J9295

Injection, necitumumab, 1mg

NDC Codes

Code

Description

00002771601

800mg/50ml 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. Portrazza prescribing information. Eli Lilly and Company, Indianapolis, IN. November 2015

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Policy activity

  • 02/16/2016 - Date of origin
  • 04/28/2017 - Effective date
Review date
  • 02/2017

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