UTILIZATION MANAGEMENT MEDICAL POLICY
Defines prior authorization and medical necessity criteria, dosing, and exclusions for medical-benefit coverage of Padcev (enfortumab vedotin-ejfv) for adults with locally advanced or metastatic urothelial carcinoma, including use as first-line in combination with pembrolizumab or as subsequent therapy.
Removed requirement that patient has tried at least one other systemic therapy.
Added requirement that Padcev is used as first-line therapy in combination with Keytruda OR Padcev is used as subsequent therapy.
Added dosing regimen of up to 125 mg administered intravenously no more frequently than twice in each 21-day cycle.
Annual Revision, Review Date updated to 01/29/2025.
Coverage Summary
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.