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