talimogene laherparepvec (Imlygic®)

OFFICE ADMINISTRATION - INTRALESIONAL INJECTION 

Indications for Prior Authorization:

Melanoma, unresectable

  • Treatment (local) of unresectable cutaneous, subcutaneous, and nodal lesions in patients with melanoma recurrent after initial surgery
  • Limitations of use: Has not been shown to improve overall survival or have an effect on visceral metastases

All of the following must be met as a condition for coverage:

  • Treatment (local) of unresectable cutaneous, subcutaneous, and nodal lesions in patients with melanoma recurrent after initial surgery
  • Patient has not responded to, tried/failed, or is unable to take Yervoy

This Medication is Not Approvable for the following condition(s):

  • Any condition not listed above as an approved indication

Dosing:

Maximum dose

  • The total injection volume for each treatment visit (for all injected lesions combined) is 4 mL according to the prescribing information

Approval: 

One year


 

Last review date: July 25, 2016

The site you are transferring to is not hosted by WHA. WHA's Terms of Use and internet Privacy Practices do not apply to your use of this linked site. Please review the policies on privacy and terms of use for the linked site. WHA does not control the accuracy, completeness, or timeliness of the content on the linked site.

Press Esc to cancel

El sitio Web al que está siendo transferido no es provisto por WHA. Las Condiciones de Uso y las Prácticas de Privacidad en Internet de WHA no se aplican a este sitio Web asociado que usted está usando. Revise las políticas sobre la privacidad y condiciones de uso de este sitio Web asociado. WHA no tiene control sobre la exactitud, la totalidad o la actualidad del contenido del sitio Web asociado. WHA no puede garantizar que los servicios de traducción de idiomas estarán disponibles en el sitio vinculado.

Presione «Esc» para cancelar