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