Imlygic
Drug - Imlygic® (talimogene laherparepvec) [Amgen Inc]
January 2018
Therapeutic area - Oncology
Approval criteria
- Patient must be 18 years of age or older AND
- Patient must have a diagnosis of unresectable cutaneous, subcutaneous, or nodular melanoma AND
- Disease must be recurrent after initial surgery
- Documentation of diagnosis must be provided at time of request
Quantity limit
- Maximum of 4 mL (total dose) per treatment session
- Volume requested must be supported by lesion(s) number and size documentation
Approvals
- Initial approval will be limited to 6 months in duration
- Renewal approval will be limited to 12 months in duration
- Documentation must be supplied at time of request showing patient is responsive to treatment
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411