Notification of Reimbursement Policy Revisions Effective June 1, 2023 (Posted April 1, 2023)

April 01, 2023

Medical Guidelines	Reason for Update
Gonadotropin Releasing Hormone Therapy	Original medical policy criteria issued. Policy notification given 4/1/2023 for effective date 7/1/2023.
Injectable and Healthcare Administered Oncology Drugs	Added Pemfexy (pemetrexed) for treatment of locally advanced or metastatic non-squamous non-small cell lung cancer (NSCLC) and for treatment of malignant pleural mesothelioma in patients whose disease is unresectable or who are otherwise not candidates for curative surgery, and added HCPCS code J9304 and associated dosing to FDA label reference table. Removed Blenrep (belantamab mafodotin-blmf) from policy due to FDA market withdrawal based on the confirmatory clinical trial not meeting requirements of FDA Accelerated Approval regulations; Blenrep is now only available for continued use through the manufacturer’s compassionate use program. Removed Zoladex (goserelin) from policy and added it to a separate individual policy (Gonadotropin Releasing Hormone Therapy). Policy notification given 4/1/2023 for effective date 7/1/2023.

Medical Guidelines

Reason for Update

Gonadotropin Releasing Hormone Therapy

Original medical policy criteria issued. Policy notification given 4/1/2023 for effective date 7/1/2023.

Injectable and Healthcare Administered Oncology Drugs

Added Pemfexy (pemetrexed) for treatment of locally advanced or metastatic non-squamous non-small cell lung cancer (NSCLC) and for treatment of malignant pleural mesothelioma in patients whose disease is unresectable or who are otherwise not candidates for curative surgery, and added HCPCS code J9304 and associated dosing to FDA label reference table. Removed Blenrep (belantamab mafodotin-blmf) from policy due to FDA market withdrawal based on the confirmatory clinical trial not meeting requirements of FDA Accelerated Approval regulations; Blenrep is now only available for continued use through the manufacturer’s compassionate use program. Removed Zoladex (goserelin) from policy and added it to a separate individual policy (Gonadotropin Releasing Hormone Therapy). Policy notification given 4/1/2023 for effective date 7/1/2023.

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