| Effective Date:10/01/2020 |
Title:Trodelvy (sacituzumab)
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| Revision Date:01/01/2021
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Document:BI663:00
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| CPT Code(s):C9066, J9317
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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)
Trodelvy (sacituzumab)
requires prior authorization.
2)
Trodelvy is used to treat
adults with metastatic triple-negative breast cancer.
3)
Trodelvy is a specialty
medication covered under the medical benefit.
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Medical Statement
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Trodelvy (sacituzumab) is considered medically necessary for members meeting all
of the following criteria:
1)
Diagnosis of metastatic
triple-negative breast cancer (mTNBC);
2)
Member has received at
least two prior therapies for metastatic disease
3)
Member is > 18
years of age
Initial authorization is for 6 months.
Reauthorization (12 months) is approved if documentation provided of tumor
response with disease stabilization or reduction of tumor size and spread.
Codes
Used In This BI:
1)
No current specific HCPCS
2)
J9317
Injection, sacituzumab govitecan-hziy, 2.5 mg
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Limits
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Intentially left empty
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Reference
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1)
Trodelvy Prescribing
Information. Morris Plains, NJ: Immunomedics, Inc.; April 2020.
2)
NCCN Drugs and Biologics
Compendium. Accessed online 08-11-2020.
Addendum:
1)
Effective 01-01-2021:
New code J9317- replaces code C9066.
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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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