CurrentCentenePolicy CP.PHAR.320

Necitumumab (Portrazza) - Clinical Coverage Criteria

Clinical coverage criteria and utilization management requirements for necitumumab (Portrazza) primarily for first-line treatment of metastatic squamous non-small cell lung cancer for Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyNecitumumab (Portrazza) - Clinical Coverage Criteria

Policy CodePolicy CP.PHAR.320

Change TypeOperational — approval duration revised

Effective DateMar 1, 2017

Next Review Date

Key ActionSubmit prior authorization with supporting clinical documentation to confirm member meets initial or continued therapy criteria.

SourceLink

POLICY UPDATE CHANGES

Extended initial approval duration from 6 months to 12 months for this maintenance medication for a chronic condition.

800 mgper-infusion maximum dose

Days 1 & 8 q3wdosing schedule

J9295HCPCS

12 moapproval duration

Cardiopulmonary arrestboxed warnings

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