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Coverage criteria policies

Ipilimumab (Yervoy®) – Minnesota Health Care Programs

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

Ipilimumab (Yervoy) requires prior authorization from HealthPartners Pharmacy Administration.

Authorization criteria:

  1. Patient has unresectable or metastatic melanoma; and,
  2. Patient has previously been treated with one or more of the following: aldesleukin, dacarbazine, temozolomide, fotemustine, or carboplatin; and,
  3. Prescriber provides weight of patient and dose of Yervoy being requested; doses >3 mg/kg will not be approved

Approvals are limited to 3 months.

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.

The services associated with these codes require prior authorization:
HCPCS Codes

Codes

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. https://mn.gov/dhs/partners-and-providers/policies-procedures/minnesota-health-care-programs/provider/types/rx/pa-criteria/yervoy.jsp

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Policy activity

  • 05/07/2018 - Date of origin
  • 10/01/2018 - Effective date

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