Medical Policy

Effective Date:05/15/2007 Title:Zolinza (Vorinostat)
Revision Date:01/01/2019 Document:BI197:00
CPT Code(s):There currently is no code for Zolinza
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Zolinza is an oral medication used to treat refractory skin lymphomas.

2)    Zolinza requires pre-authorization.

Medical Statement

1)    Zolinza (Vorinostat) is eligible for benefits for the treatment of cutaneous T-cell lymphomas (CTCL) such as mycosis fungoides or Sezary syndrome (leukemic eyrthrodermic variant) under the following criteria:

a)    Stage IIB or greater.

b)    Has failed at least one other systemic therapy such as interferon and methotrexate.

c)    Has failed adequate trial (i.e. 3 months) or been intolerant to Poteligeo (mogamulizumab)

d)    This medication must be prescribed either by a dermatologist or by an oncologist.

Limits

Zolinza is not covered for other uses.

Reference

U.S. Food and Drug Administration, FDA News Oct. 6, 2006 at: http://www.fda.gov/bbs/topics/NEWS/2006/NEW01484.html

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.