BlueCross BlueShield of Tennessee Medical Policy Manual

Pemetrexed

NDC CODE(S)

00002-7640-XX - Alimta 100mg powder for injection (Eli Lilly)

 

00002-7623-XX - Alimta 500mg powder for injection (Eli Lilly)

DESCRIPTION

Pemetrexed is a folate analog metabolic inhibitor.  It interferes with cell metabolic processes by disrupting the folate-dependent processes required for cell replication by inhibiting the biosynthesis of thymidine and purine nucleotides.  This prevents the formation of the DNA and RNA required for the growth and survival of both cancer and normal cells.

REFER TO DECISION SUPPORT TREE

POLICY

·         Pemetrexed for the treatment of the following is considered medically necessary if the medical appropriateness criteria are met: (See Medical Appropriateness below.)

·         Pemetrexed for the treatment of other conditions/diseases is considered investigational.  

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

RENEWAL CRITERIA

INDICATION(S)

DOSAGE & ADMINISTRATION

All indications

500mg/m2 every 21 days

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION 

For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).

No controlled studies were found in the published literature that validate the use of pemetrexed for the treatment of any other conditions or diseases.

SOURCES

Lexi-Comp Online. (2017). AHFS DI. Pemetrexed. Retrieved February 13, 2017 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2017, February). Pemetrexed. Retrieved February 13, 2017 from MICROMEDEX Healthcare Series.  

National Comprehensive Cancer Network. (2017). NCCN Drugs & Biologics Compendium™. Pemetrexed. Retrieved February 13, 2017 from the National Comprehensive Cancer Network.

U. S. Food and Drug Administration. (2013, September). Center for Drug Evaluation and Research. Alimta® (pemetrexed). Retrieved February 13, 2017 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/021462s045lbl.pdf.

ORIGINAL EFFECTIVE DATE:  10/8/2005

MOST RECENT REVIEW DATE:  3/14/2017

ID_MRx

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment. 

Pharmaceutical Decision Support Tree

Pemetrexed (Alimta®)

  1. Is this the initial request for this agent?

If yes, go to question #2

If no, go to question #10

  1. Does the individual have a diagnosis of bladder cancer with histology of urothelial carcinoma, squamous cell carcinoma or adenocarcinoma if the location is ANY ONE of the following?

If yes, go to question #3

If no, go to question #4

  1. Does the individual show evidence of ALL of the following?

If yes, go to question #9

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Does the individual have a diagnosis of central nervous system (CNS) cancer further diagnosed as primary CNS lymphoma that is ALL of the following?

If yes, go to question #9

If no, go to question #5

  1. Does the individual have a diagnosis of non-squamous non-small cell lung cancer (NSCLC) for treatment that is ANY ONE of the following?

If yes, go to question #9

If no, go to question #6

  1. Does the individual have a diagnosis of malignant pleural mesothelioma requesting treatment used in combination with cisplatin or carboplatin OR as a single agent?

If yes, go to question #9

If no, go to question #7

  1. Does the individual have a diagnosis of ovarian cancer diagnosed as epithelial ovarian cancer, fallopian tube cancer or primary peritoneal cancer and disease is persistent or recurrent for single-agent therapy?

If yes, go to question #9

If no, go to question #8

  1. Does the individual have a diagnosis of thymomas / thymic carcinomas requesting second-line treatment for single agent therapy?

If yes, go to question #9

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Is the request for 130 billable units or less every 21 days for dosing of 500 mg/m2 every 21 days for an authorization period of six months with possible renewal?

If yes, this satisfies medical necessity and medical appropriateness criteria

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Does the individual continue to meet initial approval criteria in questions 2 through 9?

If yes, go to question #11

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Is there response to treatment indicated by stabilization of disease or decrease in size of tumor or tumor spread with absence of unacceptable toxicity from the agent?

If yes, this satisfies medical necessity and medical appropriateness criteria

If no, this does not meet medical necessity and/or medical appropriateness criteria

This document has been classified as public information.