WHA

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:

Last review date: August 16, 2022