CurrentMass General Brigham Health PlanPolicy N/A
Jemperli (dostarlimab) Effective 03/01/2025
Covers prior authorization, clinical criteria, continuation, and limits for Jemperli (dostarlimab) for commercial/exchange plans (MassHealth UPPL Plan references) including indications: dMMR recurrent/advanced solid tumors, dMMR recurrent/advanced endometrial cancer, and primary advanced or recurrent endometrial cancer (combination with carboplatin + paclitaxel followed by monotherapy).
Policy Summary
PayerMass General Brigham Health Plan
PolicyJemperli (dostarlimab) Effective 03/01/2025
Policy CodePolicy N/A
Change TypeAdded indication; clarified regimen criteria; operational language updates
Effective DateMar 1, 2025
Next Review Date
Key ActionPrior authorization required; submit requests for members new to the plan within 90 days who are actively receiving therapy or when all clinical criteria for the specified indication are met.
SourceLink
POLICY UPDATE CHANGES
Added supplemental indication of primary advanced or current endometrial cancer.
Updated criteria for primary advanced or recurrent endometrial cancer to clarify when Jemperli should be used in the regimen.
Removed requirement for appropriate dosing and updated specialist prescriber verbiage; updated verbiage for members new to the plan.
3Covered Indications
12 monthsApproval Duration
>=18