CurrentmhnPolicy CP.PHAR.91

Vemurafenib (Zelboraf)

Defines medical necessity, prior authorization, and coverage criteria for vemurafenib (Zelboraf) across multiple indications for members covered by the payer (includes Commercial, HIM, Medicaid). Affects prescribers and providers requesting coverage.

Policy Summary

Payermhn

PolicyVemurafenib (Zelboraf)

Policy CodePolicy CP.PHAR.91

Change TypeNo material changes

Effective DateNov 1, 2011

Next Review DateN/A

Key ActionProvider must submit documentation (office notes, labs, or other clinical information) demonstrating the member meets all approval criteria including BRAF V600 mutation positivity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

BRAF V600 requiredMolecular test requirement

Wild-type BRAFExcluded population

12 monthsApproval duration

1,920 mg/dayDose ceiling

Coverage Criteria

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.

Melanoma initial criteria: 1. Diagnosis of recurrent, lymph node positive, unresectable, or metastatic melanoma; 2. Prescribed by or in consultation with an oncologist; 3. Age >= 18 years; 4. Positive for a BRAF V600 mutation; 5. For Zelboraf requests, member must use generic vemurafenib if available unless contraindicated or clinically significant adverse effects are experienced; 6. Request meets one of the following: a. Dose does not exceed 1,920 mg (8 tablets) per day; or b. Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence); 7. Prescribed regimen must be FDA-approved or recommended by NCCN.

Approval duration: Medicaid/HIM - 12 months; Commercial - 12 months or duration of request, whichever is less

Initial Approval — Histiocytic Neoplasms