CurrentMass General Brigham Health PlanPolicy N/A

Imdelltra (tarlatamab-dlle)

Defines prior authorization, coverage criteria, continuation and limitations for Imdelltra (tarlatamab-dlle) under the pharmacy benefit for Mass General Brigham Health Plan / MassHealth UPPL for commercial/exchange members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyImdelltra (tarlatamab-dlle)

Policy CodePolicy N/A

Change TypeCreated/adopted

Effective DateNov 12, 2024

Next Review Date

Key ActionPrior authorization is required under the pharmacy benefit; requests for members new to the plan who are currently receiving treatment may be reviewed case-by-case (excluding samples or manufacturer patient assistance program supplies).

SourceLink

POLICY UPDATE CHANGES

Policy created/adopted for Imdelltra using MassHealth criteria

6 monthsInitial/Reauthorization Duration

ES-SCLCCovered Indication

Coverage Summary

Coverage stance: covered_with_criteria. Indicated population: adult patients with extensive-stage small cell lung cancer (ES-SCLC) with disease progression on or after platinum-based chemotherapy. Benefit scope: covered under the pharmacy benefit for commercial/exchange MassHealth UPPL members. Payer alignment and administrative details: policy aligns with MassHealth/UPPL criteria, requires prior authorization (prescriber must be an oncologist), documents inadequate response/adverse reaction/contraindication to one platinum-based chemotherapy, and initial approvals/reauthorizations are granted for 6 months.

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Members New to the Plan

Authorization consideration for members currently receiving therapy:

Members New to the Plan: Authorization may be reviewed on a case by case basis for members who are new to the plan currently receiving treatment with requested medication

Excludes products obtained as samples or via manufacturer's patient assistance programs

Provider Actions

Prior Authorization

Prior authorization required

Imdelltra requires prior authorization under the pharmacy benefit; requests for members new to the plan who are currently receiving treatment may be reviewed case-by-case (excluding samples or manufacturer patient assistance program supplies).

Case-by-case review may be performed for members new to the plan who are currently receiving treatment (excludes samples and manufacturer's patient assistance program supplies).

Documentation Required

Prescriber specialty requirement

Prescriber must be an oncologist for approval.

Documentation Required

Prior therapy documentation

Documentation must show inadequate response, adverse reaction, or contraindication to one platinum-based chemotherapy.

Billing Rule

Authorization duration

Initial approvals and reauthorizations will be granted for 6 months.

Background

Indication statement: Imdelltra (tarlatamab-dlle) is indicated for the treatment of adult patients with extensive-stage small cell lung cancer (ES-SCLC) with disease progression on or after platinum-based chemotherapy.

Alignment with MassHealth/UPPL criteria: Authorization requires that the prescriber be an oncologist, appropriate dosing is used, and documentation shows inadequate response, adverse reaction, or contraindication to ONE platinum-based chemotherapy. Members new to the plan who are currently receiving the medication may be reviewed on a case-by-case basis (excluding products obtained as samples or via manufacturer patient assistance programs).

Policy scope summary: Imdelltra is managed under the pharmacy benefit, requires prior authorization, and initial approvals and reauthorizations are granted for 6 months. Continuation of therapy requires resubmission by the prescriber which will infer a positive response to therapy.

Policy Summary

PayerMass General Brigham Health Plan

PolicyImdelltra (tarlatamab-dlle)

Policy CodePolicy N/A

Change TypeCreated/adopted

Effective DateNov 12, 2024

Next Review Date

SourceLink

On This Page

OpenPayer

Imdelltra (tarlatamab-dlle)

Coverage Summary

Initial Therapy Criteria

Members New to the Plan

Continuation Therapy Criteria (Reauthorization)

Provider Actions

Applicable Codes

Clinical Evidence & References

Background

Revision History