CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Um Onc_1335 Braftovi Encorafenib_01312025

Defines clinical inclusion and exclusion criteria, coding, and utilization management/approval authority for Braftovi (encorafenib) for FDA-approved and select off-label oncologic indications across colorectal cancer, melanoma, and NSCLC for Neighborhood Health Plan of Rhode Island (Evolent UM).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUm Onc_1335 Braftovi Encorafenib_01312025

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 31, 2025

Next Review Date

Key ActionMedication requests must be processed/authorized by Evolent Utilization Management; medications not authorized may be deemed not approvable and not reimbursable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this policy update.

3Covered Indications (CRC, Melanoma, NSCLC)

3Exclusion Criteria Types

2Combination Agents Specified

Coverage Summary

Coverage stance: covered_with_criteria. This policy defines clinical inclusion and exclusion criteria, coding, and utilization management/approval authority for Braftovi (encorafenib) for FDA-approved and select off‑label oncologic indications across colorectal cancer, melanoma, and NSCLC for Neighborhood Health Plan of Rhode Island (Evolent UM).

Subject: Braftovi (encorafenib) coverage policy. Scope: Defines clinical inclusion and exclusion criteria, coding, and utilization management/approval authority for Braftovi (encorafenib) for FDA‑approved and select off‑label oncologic indications across colorectal cancer, melanoma, and NSCLC for Neighborhood Health Plan of Rhode Island (Evolent UM). Payer/UM metadata: Evolent Utilization Management (UM) is responsible for processing medication requests and enforcing the coverage criteria; medications not authorized by Evolent may be deemed not approvable and not reimbursable.

Initial Therapy Criteria — Indication-specific Inclusion

Colorectal Cancer — Inclusion Criteria

Covered when ALL of the following are met:

ALL of the following

Member has BRAF V600E mutation positive unresectable or metastatic colorectal cancer, regardless of KRAS/NRAS status
Braftovi (encorafenib) will be used in combination with Erbitux (cetuximab) or Vectibix (panitumumab) after prior therapy with an oxaliplatin and/or irinotecan containing regimen
Initial-line option
- Braftovi (encorafenib) may be used in combination with Erbitux (cetuximab) and FOLFOX in the initial line setting in members with stage IV, metastatic BRAF V600E mutation positive colorectal cancer, and KRAS/NRAS status is either Wild-Type or unknown
Additional member requirements for initial-line use
- Have not had prior treatment with any selective BRAF inhibitors or EGFR inhibitors
- Have tumors that are not microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) unless the member is ineligible to receive immune checkpoint inhibitors

Melanoma — Inclusion Criteria

Covered when ALL of the following are met:

ALL of the following

Braftovi (encorafenib) used in combination with Mektovi (binimetinib)
Member has BRAF V600E or V600K mutation positive unresectable or metastatic melanoma

Non-Small Cell Lung Cancer (NSCLC) — Inclusion Criteria

Covered when ALL of the following are met:

ALL of the following

Braftovi (encorafenib) used in combination with Mektovi (binimetinib)
Member has BRAF V600E mutation positive metastatic non-small cell lung cancer (NSCLC)