| Effective Date:05/01/2017 |
Title:Lartruvo (Olaratumab)
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| Revision Date:01/01/2018
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Document:BI536:00
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| CPT Code(s):J9285
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Public Statement
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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)
Lartruvo (Olaratumab)
requires prior authorization.
2)
Lartruvo is
used to treat soft tissue sarcomas.
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Medical Statement
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Lartruvo (Olaratumab) is
considered medically necessary for patients meeting the following criteria:
1)
Patient is
18 years of age or older AND
2)
Patient has
a diagnosis of soft tissue sarcoma AND
3)
Tumor has a
histologic subtype for which an anthracycline-containing regimen is appropriate
AND
4)
Tumor is
not amenable to curative treatment with radiotherapy or surgery
5)
Is used in
combination with doxorubicin
Codes
Used In This BI:
C9485 Injection, Olaratumab (deleted 1/1/18)
J9285
Injection, Olaratumab (new 1/1/18)
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Limits
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Intentially left empty
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Reference
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1)
Lartruvo
Package Insert. Eli Lilly and Company. Indianapolis, IN. October 2016.
2)
Clinical
Pharmacology. Accessed online 3/23/2017
3)
NCCN Drugs
and Biologic Compendium. Accessed online 3/23/2017.
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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