Continuation of Therapy — Elahere (mirvetuximab soravtansine-gynx)
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Policy governs prior-authorization and continuation/reauthorization criteria for medical-benefit use of Elahere for members (MassHealth UPPL) continuing therapy when new to the plan or requesting ongoing treatment.
Added age requirement of 18 years and older.
Clarified that consult notes can be accepted for prescriber specialty (oncologist).
Removed chemotherapy alternatives and replaced with reference to current NCCN Guidelines for treatment options.
Authorization and Continuation Criteria
Authorization and continuation criteria
Authorization may be granted when documentation shows the following criteria are met:
ALL of the following
- Diagnosis of platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer
- Member is ≥ 18 years of age
- Prescriber is an oncologist OR consult notes from an oncologist are provided
- Appropriate dosing documented (weight required)
- Member is folate receptor alpha (FRα / FOLR1) positive
- Inadequate response or adverse reaction to ONE systemic therapy, OR contraindication to use of ALL systemic therapy for the requested indication (refer to current NCCN Guidelines for available treatment options)
Continuation / case-by-case
- Members new to the plan who are currently receiving the medication may be reviewed for continuation (excludes samples and manufacturer's patient assistance)
- Reauthorization by the prescriber will infer a positive response to therapy
Salvage (line of therapy)
Coding and Prior Therapy Requirements
| No codes listed |
Provider Requirements and Authorization Process
Prior authorization required; case‑by‑case continuation for new members
Prior authorization is required for medical‑benefit use of Elahere; members who are new to the plan but currently receiving the medication (excluding samples or manufacturer patient assistance) may be reviewed on a case‑by‑case basis for continuation.
- Plan: MassHealth UPPL; Benefit type: Medical Benefit
- Program Type: Prior Authorization
- Case‑by‑case continuation applies to members new to the plan who are currently receiving the medication (samples and manufacturer patient assistance excluded)
Prescriber must be an oncologist or provide oncologist consult notes
The prescriber must be an oncologist, or the request must include consult notes from an oncologist to meet the coverage criteria.
- This requirement is listed as criterion #3 in the authorization criteria.
Reauthorization by prescriber infers positive response
When a prescriber submits a reauthorization request, the plan will interpret that reauthorization as evidence of a positive clinical response to therapy.
- Reauthorization inference is stated under Continuation of Therapy.
Indication and Biomarker Definitions
FRα / FOLR1 Testing Requirement
Elahere (mirvetuximab soravtansine-gynx) — Covered Use
| Regimen | Indication | Coverage status | Supporting notes |
|---|---|---|---|
| Elahere (mirvetuximab soravtansine-gynx) | FRα-positive, platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer after prior systemic therapy (1–3 prior regimens) | Covered | Indicated for adult patients with FRα (FOLR1) positive disease in the platinum‑resistant setting; prior authorization required for medical‑benefit use. Initial approvals may be granted for 6 months with reauthorizations up to 12 months. Refer to current NCCN Guidelines for alternative systemic therapy options. |
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