| Effective Date:01/01/2021 |
Title:Zepzelca (lurbinectedin)
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| Revision Date:
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Document:BI681:00
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| CPT Code(s):J9223
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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)
Zepzelca (lurbinectedin)
requires prior authorization.
2)
Zepzelca is used to treat
lung cancer.
3)
Zepzelca is a specialty
medication covered under the medical benefit.
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Medical Statement
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Zepzelca (lurbinectedin) is considered medically necessary for members meeting
the following criteria:
Small Cell Lung Cancer
(must meet all)
1)
Diagnosis of advanced or
metastatic small cell lung cancer (SCLC);
2)
Prescribed by or in
consultation with an oncologist;
3)
Age > 18 years;
4)
Failure of a
platinum-containing regimen (e.g. cisplatin, carboplatin), unless clinically
significant adverse effects are experienced or all are contraindicated;
5)
Dose does not exceed
3.2mg/m2 every 21 days.
Approval Duration: 6
months
Reauthorization (12
months) is approved if member responding positively to therapy and dosing does
not exceed 3.2mg/m2 every 21 days.
Codes
Used In This BI:
1)
J9223
Injection, lurbinectedin, 0.1 mg
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Limits
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Intentially left empty
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Reference
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1)
Zepzelca Prescribing
Information. Palo Alto, CA: Jazz Pharmaceuticals, Inc.; June 2020.
2)
NCCN Drugs and Biologics
Compendium. Accessed online November 25, 2020.
Addendum:
1)
Effective 01-01-2021:
New code J9223
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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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