Cigna National Formulary Coverage Policy
Prior Authorization Oncology (Injectable) – Gonadotropin-Releasing Hormone Analogs - Firmagon® (degarelix for subcutaneous injection)
Table of Contents Product Identifier(s)
National Formulary Medical Necessity ...... 1 65462 Conditions Not Covered...... 2 Background ...... 2 References ...... 2 Revision History ...... 2
INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.
National Formulary Medical Necessity
Cigna covers Degarelix (Firmagon®) as medically necessary when the following criteria are met for FDA Indications or Other Uses with Supportive Evidence:
Prior Authorization is recommended for prescription benefit coverage Firmagon. All approvals are provided for the duration noted below. Because of the specialized skills required for evaluation and diagnosis of patients treated with Eligard, Firmagon, and Trelstar as well as the monitoring required for adverse events and long-term efficacy, approval requires these agents to be prescribed by or in consultation with a physician who specializes in the condition being treated.
FDA Indication(s)
1. Prostate Cancer. Approve Firmagon for 1 year if prescribed by, or in consultation with, an oncologist.1,3
Page 1 of 2 Cigna National Formulary Coverage Policy: PA Oncology (Injectable) – Gonadotropin-Releasing Hormone Analogs - Firmagon Conditions Not Covered
Degarelix (Firmagon®) is considered experimental, investigational or unproven for ANY other use.
Background
Overview Eligard, Trelstar, and Firmagon are all indicated for the treatment of advanced prostate cancer.1-3 Eligard and Trelstar are gonadotropin-releasing hormone (GnRH) agonists, whereas Firmagon is a GnRH antagonist. Both Eligard and Firmagon are as a subcutaneous injection and Trelstar is administered as an intramuscular injection.
Guidelines The National Comprehensive Cancer Network (NCCN) Guidelines for Head and Neck Cancer (version 1.2021 – November 9, 2020) recommend the use of androgen receptor therapy (i.e., leuprolide, bicalutamide) for androgen receptor (AR)-positive, recurrent salivary gland tumors with distant metastases.4,5
The NCCN Guidelines for Prostate Cancer (version 3.2020 – November 17, 2020) note androgen deprivation therapy as primary systemic therapy for regional or advanced prostate cancer and as neoadjuvant/concomitant/adjuvant therapy in combination with radiation in localized or locally advanced prostate cancer.6 Many different drugs can be used as androgen deprivation therapy, including Eligard, Firmagon, and Trelstar.
References
1. Eligard® Subcutaneous Injection [prescribing information]. Fort Collins, CO: Tolmar Pharmaceuticals Inc.; April 2019. 2. Firmagon® Subcutaneous Injection [prescribing information]. Parsippany, NJ: Ferring Pharmaceuticals Inc.; February 2020. 3. Trelstar® Intramuscular Injection [prescribing information]. Wayne, PA: Verity Pharmaceuticals, Inc; May 2020. 4. The NCCN Head and Neck Cancer Clinical Practice Guidelines in Oncology (Version 1.2021 – November 9, 2020). © 2020 National Comprehensive Cancer Network, Inc. Available at: http://www.nccn.org. Accessed November 24, 2020. 5. The NCCN Drugs and Biologics Compendium. © 2020 National Comprehensive Cancer Network, Inc. Available at: http://www.nccn.org. Accessed on November 24, 2020. Search terms: leuprolide acetate, degarelix, triptorelin pamoate. 6. The NCCN Prostate Cancer Clinical Practice Guidelines in Oncology (Version 3.2020 – November 17, 2020). © 2020 National Comprehensive Cancer Network, Inc. Available at: http://www.nccn.org. Accessed on November 24, 2020.
Revision History
Type of Revision Summary of Changes Review Date Annual Revision No criteria changes. 12/09/2020
“Cigna Companies” refers to operating subsidiaries of Cigna Corporation. All products and services are provided exclusively by or through such operating subsidiaries, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., QualCare, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2021 Cigna.
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