LOQTORZI (toripalimab-tpzi)

Office-Administration – intravenous infusion

Diagnosis considered for coverage:

Nasopharyngeal carcinoma (NPC): Indicated, in combination with cisplatin and gemcitabine, for the first-line treatment of adults with metastatic or with recurrent, locally advanced NPC. Indicated, as a single agent, for the treatment of adults with recurrent unresectable or metastatic NPC with disease progression on or after a platinum-containing chemotherapy.

Coverage Criteria:

For diagnosis of nasopharyngeal carcinoma (NPC):

  • Diagnosis of nasopharyngeal carcinoma (NPC); AND
  • Disease is one of the following: 
    • metastatic 
    • recurrent and locally advanced; AND 
  • One of the following: 
    • All of the following: 
      • Loqtorzi is being used as first line NPC treatment 
      • Loqtorzi is being used in combination with cisplatin and gemcitabine 
      • Treatment duration of Loqtorzi has not exceeded a total of 24 months during the patient's lifetime, OR
    • Both of the following: 
      • Loqtorzi is being used as recurrent NPC treatment 
      • Disease has progressed on or after a platinum containing chemotherapy 
Reauthorization Criteria:

For diagnosis of NPC:

  • All of the following: 
    • Loqtorzi is being used as first line NPC treatment 
    • Patient does not show evidence of progressive disease while on therapy 
    • Treatment duration of Loqtorzi has not exceeded a total of 24 months during the patient's lifetime; OR
  • Both of the following: 
    • Loqtorzi is being used as recurrent NPC treatment
    • Patient does not show evidence of progressive disease while on therapy
Dosing:
  • First-line treatment of RM-NPC in combination with gemcitabine-cisplatin
    • 240 mg IV every 3 weeks until disease progression, unacceptable toxicity, or up to 24 months
  • Treatment as a single agent of RM-NPC with disease progression on or after chemotherapy
    • 3 mg/kg IV every 2 weeks until disease progression or unacceptable toxicity
Coverage Duration: 
  • Initial: 1 year
  • Reauthorization: 1 year
Authorization is not covered for the following:
  • The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.
Policy Updates:
  • 06/01/2024 – New policy for Loqtorzi approved by WHA P&T Committee. (P&T, 05/21/2024)
References:
  1. Loqtorzi Prescribing Information.Coherus BioSciences, Inc. Redwood City, CA. October 2023 

Last review date: June 1, 2024

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