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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


  • 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


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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