BlueCross BlueShield of Tennessee Medical Policy Manual

Pemetrexed

NDC CODE(S)

00002-7640-XX Alimta 100 MG SOLR (LILLY)

 

00002-7623-XX Alimta 500 MG SOLR (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.

POLICY

MEDICAL APPROPRIATENESS

INITIAL APPROVAL

Genomic Aberration Targeted Therapies (not all inclusive)

Sensitizing EGFR mutation-positive tumors

Erlotinib

Afatinib

Gefitinib

Osimertinib

ALK rearrangement-positive tumors

Crizotinib

Ceritinib

Brigatinib

Alectinib

ROS1 rearrangement-positive tumors

Crizotinib

Ceritinib

BRAF V600E-mutation positive tumors

Dabrafenib/Trametinib

PD-L1 expression-positive tumors (>50%)

Pembrolizumab

 

RENEWAL CRITERIA

INDICATION(S)

DOSAGE & ADMINISTRATION

All indications

500mg/m2 every 21 days

LENGTH OF AUTHORIZATION

Coverage will be provided for six months and may be renewed

Click here to view DOSAGE LIMITS

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 or prevention of other conditions or diseases.

SOURCES

Lexi-Comp Online. (2018). AHFS DI. Pemetrexed. Retrieved February 16, 2018 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2017, October). Pemetrexed. Retrieved February 16, 2018 from MICROMEDEX Healthcare Series.  

National Comprehensive Cancer Network. (2018). NCCN Drugs & Biologics Compendium™. Pemetrexed. Retrieved February 16, 2018 from the National Comprehensive Cancer Network.

U. S. Food and Drug Administration. (2017, October). Center for Drug Evaluation and Research. Alimta®  (pemetrexed). Retrieved February 16, 2018 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021462s050lbl.pdf. 

ORIGINAL EFFECTIVE DATE:  10/8/2005

MOST RECENT REVIEW DATE:  5/8/2018

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

DIAGNOSIS

BILLABLE UNIT

MAXIMUM UNITS

All indications

1 billable unit = 10mg

130 billable units every 21 days