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)    Portrazza (necitumumab) requires prior authorization.

2)    Portrazza is used to treat a type of lung cancer.

3)    Portrazza is considered a specialty drug and is covered under the medical benefit.

Portrazza (necitumumab) is considered medically necessary for patients meeting all of the following criteria:

1)    Diagnosis of metastatic squamous non-small cell lung cancer (NSCLC) AND

2)    Is used in combination with gemcitabine and cisplatin.

Portrazza (necitumumab) is considered experimental and investigational for the treatment of other solid tumors (not an all-inclusive list):

·       Colorectal cancer

·       Head and neck squamous cell carcinoma

·       Non-squamous NSCLC

1)    Aetna Medical Clinical Policy Bulletin. Portrazza (necitumumab). Accessed at http://www.aetna.com/cpb/medical/data/800_899/0898.html

2)    Portrazza Product Information. Eli Lilly. Indianapolis, IN. November 2015.

3)    Clinical Pharmacology. Accessed online 03/14/2016.

Addendum:

1)    Effective 1/1/2017: added J9295 as appropriate code for Portrazza.

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.