OPDUALAG (nivolumab/relatlimab)

OPDUALAG (nivolumab/relatlimab)

Medical Administration – intravenous

Diagnosis considered for coverage:

• Indicated for the treatment of adult and pediatric patients 12 years of age or older with unresectable or metastatic melanoma.

Coverage Criteria:

For diagnosis of melanoma:

• Dose does not exceed 480 mg nivolumab and 160 mg relatlimab every 4 weeks; AND
• Prescribed by or in consultation with an oncologist; AND
• Diagnosis of one of the following:
  • Unresectable melanoma
  • Metastatic melanoma; AND
• Patient is 12 years of age or older; AND
• Patient weights at least 40 kg (88 lbs)

Reauthorization Criteria:

For diagnosis of melanoma:

• Dose does not exceed 480 mg nivolumab and 160 mg relatlimab every 4 weeks; AND
• Patient does not show evidence of progressive disease while on therapy

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.

Additional Information:

• Dosing:
  • 480 mg nivolumab and 160 mg relatlimab are administered intravenously every 4 weeks until disease progression or unacceptable toxicity occurs
  • Pediatrics: recommended dosage for pediatric patients 12 years of age or older who weigh less than 40 kg has not been established.
• Administration:
  • Administer Opdualag as an intravenous infusion over 30 minutes

Policy Updates:

• 08/16/2022 – New policy approved by P&T.

References:

• Opdualag Prescribing Information. Bristol-Myers Squibb. Princeton, NJ. March 2022.
• National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology – Melanoma: Cutaneous. V3.2022 – April 11, 2022. NCCN Web site. https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf. Accessed April 19, 2022.