BlueCross BlueShield of Tennessee Medical Policy Manual

Durvalumab

NDC CODE(S)

00310-4500-XX Imfinzi 120 MG/2.4ML SOLN (ASTRAZENECA)

 

00310-4611-XX Imfinzi 500 MG/10ML SOLN (ASTRAZENECA)

DESCRIPTION

Durvalumab is a human immunoglobulin G1 kappa monoclonal antibody that blocks the interaction of programmed cell death ligand 1 (PD-L1) with the PD-1 and CD80 (B7.1) molecules.  This PD-L1 blocking antibody binds to receptors on both tumor cells and tumor-associated immune cells in the tumor microenvironment, releasing the inhibition of immune responses without inducing antibody dependent cell-mediated cytotoxicity (ADCC).  PD-L1 blockade leads to increased T-cell activation and decreased tumor size.

POLICY

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

*If platinum treatment occurred greater than 12 months ago, the individual should be re-treated with platinum-based therapy. Individuals with comorbidities (e.g., hearing loss, neuropathy, poor PS, renal insufficiency, etc.) may not be eligible for cisplatin. Carboplatin may be substituted for cisplatin particularly in those individuals with a GFR <60 mL/min or a PS of 2.

RENEWAL CRITERIA

INDICATION(S) DOSAGE & ADMINISTRATION
All indications 10 mg/kg intravenously every 14 days

LENGTH OF AUTHORIZATION

Coverage will be provided for 6 months and may be renewed

NSCLC can be authorized up to a maximum of 12 months of therapy

Refer to DOSAGE LIMITS below

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).

SOURCES

Lexi-Comp Online. (2019, Friday). AHFS DI. Durvalumab. Retrieved April 29, 2019 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2019, April). Durvalumab. Retrieved April 26, 2019 from MICROMEDEX Healthcare Series.

National Comprehensive Cancer Network. (2019). NCCN Drugs & Biologics Compendium®. Durvalumab. Retrieved April 26, 2019 from National Comprehensive Cancer Network.

National Comprehensive Cancer Network. (2018, July). NCCN Clinical Practice Guidelines in Oncology®. Bladder Cancer, version 5.2018. Retrieved October 16, 2018 from National Comprehensive Cancer Network.

U. S. Food and Drug Administration. (2018, February). Center for Drug Evaluation and Research. Imfinzi®(durvalumab) injection, for intravenous use. Retrieved April 26, 2019 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/761069s002lbl.pdf.

ORIGINAL EFFECTIVE DATE: 6/1/2017

MOST RECENT REVIEW DATE:  6/11/2019

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.

This document has been classified as public information.

 

 

DOSAGE LIMITS

Maximum billable units per dose and over time by indication as a Medical Benefit; 1 billable unit = 10 mg

DIAGNOSIS

MAXIMUM UNITS

All indications

112 billable units (1120 mg) every 14 days