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