| 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.
|