Subject: Firmagon 2147-A SGM P2023
Policy:
I. INDICATIONS
The indications below including FDA-approved indications and
compendial uses are considered a covered benefit provided
that all the approval criteria are met and the member has no
exclusions to the prescribed therapy.
A. FDA-Approved Indication
Firmagon is indicated for the treatment of patients with
advanced prostate cancer.
B. Compendial Use
Prostate cancer
All other indications are considered experimental/investigational
and not medically necessary.
II. CRITERIA FOR INITIAL APPROVAL
Prostate Cancer
Authorization of 12 months may be granted for treatment of
prostate cancer.
III. CONTINUATION OF THERAPY
Authorization of 12 months may be granted for continued
treatment in members requesting reauthorization who are
experiencing clinical benefit to therapy (e.g., serum testosterone
less than 50 ng/dL) and who have not experienced an
unacceptable toxicity.
Place of Service:
Outpatient
The above policy is based on the following references:
- Firmagon [package insert]. Parsippany, NJ: Ferring Pharmaceuticals Inc.; February 2020.
- The NCCN Drugs & Biologics Compendium® © 2023 National Comprehensive Cancer Network, Inc. http://www.nccn.org. Accessed February 1, 2023.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
August 18, 2023
