Medical Policy

Effective Date:01/01/2019 Title:Mektovi (binimetinib)
Revision Date: Document:BI594:00
CPT Code(s):
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)    Mektovi (binimetinib) and Braftovi (encorafenib) require prior authorization.

2)    Mektovi and Braftovi are used in combination to treat unresectable or metastatic melanoma.

3)    Mektovi and Braftovi are specialty drugs covered under the pharmacy benefit and must be obtained through a contracted specialty pharmacy.

Medical Statement

Mektovi (binimetinib) and Braftovi (encorafenib) are considered medically necessary to be used in combination in members meeting the following:

1)    Member is 18 years of age or older AND

2)    Diagnosis of unresectable or metastatic melanoma with BRAF V600E or V600K mutation AND

3)    Mutation has been detected by an FDA approved test AND

4)    Patient is either treatment naïve or has progressed on or after previous first-line immunotherapy (e.g. Yervoy, Keytruda, Opdivo)

 

Limits

As oral specialty drugs, Mektovi and Braftovi are limited to a maximum 30 day supply per fill and must be filled at a contracted specialty pharmacy.

Reference

1)    Mektovi Package Insert.

2)    Braftovi Package Insert.

3)    Clinical Pharmacololgy. Accessed online 11//2018.

4)    NCCN Drugs and Biologics Compendium. Accessed online 11/7/2018

5)    Drummer R, Ascierto PA, Gogas HJ, et al. Encorafenib plus binimetinib versus vemurafenib or enxorafenib in patients with BRAF-mutant melanoma (COLUMBUS): a multicenter, open-label, randomized phase 3 trial. Lancet Oncol. 2015; 16:1389-1399.

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.