Zepzelca™
Drug - Zepzelca™ (lurbinectedin injection) [Jazz Pharmaceuticals, Inc.]
March 2021
Therapeutic Area - Oncology
Initial approval criteria
- Patient is at least 18 years of age AND
- Patient has a diagnosis of metastatic small cell lung cancer (SCLC) AND
- Lurbinectedin will be used as a single agent AND
- Patient has a diagnosis of metastatic disease after disease progression on or after platinum-based chemotherapy (i.e., cisplatin, carboplatin) OR
- Patient has relapsed or progressive disease as subsequent therapy
- Initial approval is for 6 months
Renewal criteria
- Patient demonstrated disease response with treatment as defined by stabilization in disease or decrease in size of tumor/tumor spread AND
- Absence of unacceptable toxicity from the drug (myelosuppression, hepatotoxicity, etc.)
- Renewal approval is for 6 months
Quantity limits
- 3.2 mg/m2 every 21 days
- Patient’s body surface area (in m2) must be provided at time of request
Billing for Zepzelca
Zepzelca must be billed as a medical claim.
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411