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)    Cyramza (Ramucirumab) requires prior authorization.

2)    Cyramza is used to treat advanced gastric cancers, colorectal cancer, hepatocellular carcinoma and lung cancer.

3)    Cyramza is a specialty drug covered under the medical benefit.

Cyramza is considered medically necessary for members who meet the following criteria:

1)    Member has a diagnosis of advanced gastric cancer or gastro-esophageal junction adenocarcinoma  AND

2)    Member had disease progression or intolerance to a prior chemotherapy regimen containing a fluoropyrimidine- or platinum-agent

OR

3)    Member has diagnosis of metastatic colorectal cancer AND

4)    Member has experienced disease progression on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine, in combination with irinotecan, folinic acid (leucovorin), and 5-fluourouracil. 

OR

5)    Member has a diagnosis of metastatic non-small cell lung cancer (NSCLC) AND

6)    Will be used in combination with docetaxel AND

7)    Has experience disease progression on or after platinum-based chemotherapy

OR

8) Member has diagnosis of progressive hepatocellular carcinoma (HCC) AND

9) AFP > 400ng/mL AND

10) Disease has progressed on or after therapy with Nexavar

Reauthorization (after 12 months) will be provided for members who have not experienced any of the following:

1)    Severe bleeding

2)    Grade 3 or 4 infusion-related reactions

3)    Severe hypertension that cannot be controlled with optimized antihypertensive therapy

4)    Urine protein level >3 g/24 hours or in the setting of nephrotic syndrome

5)    Arterial Thrombolic events

6)    Gastrointestinal perforation

Codes Used In This BI:

J9308 – Injection, Ramucirumab, 5mg (Cyramza)

1)    Cyramza Prescribing Information.  Eli Lilly.  April 2015.

2)    Clinical Pharmacology.  Accessed online August 2016.

3)    Fuchs CS, Tomasek J, Young CJ et al. Ramucirumab monotherapy for previously treated advanced gastric or gastro-esophageal junction adenocarcinoma (REGARD): an international, randomized, multicenter, placebo-controlled, phase 3 trial. Lancet. 2014:383:31-39.

4)    NCCN Drug Compendium.  Accessed online October 2021.

Addendum:

Effective 12/01/2021: added coverage criteria for hepatocellular carcinoma.

This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.