Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.50 Subject: Keytruda Page: 1 of 9 Last Review Date: September 20, 2018 Keytruda Description Keytruda (pembrolizumab) Background Keytruda is a monoclonal antibody for the treatment of patients with advanced or unresectable melanoma, metastatic non-small cell lung cancer (NSCLC), metastatic nonsquamous non-small cell lung cancer (NSCLC), recurrent or metastatic head and neck squamous cell carcinoma (HNSCC), refractory classical Hodgkin lymphoma (chl), refractory mediastinal large B-cell lymphoma (PMBCL), recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma, microsatellite instability-high or mismatch repair deficient solid tumors that have progressed following prior treatments, and patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy whose tumors express PD- L1 (CPS 1) as determined by an FDA approved test. Keytruda blocks a cellular pathway known as PD-1, human programmed death receptor-1, which restricts the body s immune system from attacking cancer cells (1-3). Regulatory Status FDA-approved indication: Keytruda is a human programmed death receptor-1 (PD-1)-blocking antibody indicated for the treatment of: (3) 1. Patients with unresectable or metastatic melanoma 2. Patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have high PD-L1 expression [(Tumor Proportion Score (TPS) 50%)] as determined by an FDAapproved test, with no EGFR or ALK genomic tumor aberrations, and no prior systemic chemotherapy treatment for metastatic NSCLC 3. Patients with metastatic non-small cell lung cancer (NSCLC) whose tumors express PD- L1 as determined by an FDA-approved test and who have disease progression on or
Subject: Keytruda Page: 2 of 9 after platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving Keytruda 4. In combination with pemetrexed and carboplatin, as first-line treatment of patients with metastatic nonsquamous NSCLC, with no EGFR or ALK genomic tumor aberrations 5. Patients with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) with disease progression on or after platinum-containing chemotherapy 6. Adult and pediatric patients with refractory classical Hodgkin lymphoma (chl), or who have relapsed after 3 or more prior lines of therapy 7. Adult and pediatric patients with refractory primary mediastinal large B-cell lymphoma (PMBCL), or who have relapsed after 2 or more prior lines of therapy 8. Patients with locally advanced or metastatic urothelial carcinoma: a. who are not eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1 [Combines Positive Score (CPS) 10] as determined by an FDAapproved test, or b. who are not eligible for any platinum containing chemotherapy regardless of PD- L1 status, or c. who have disease progression during or following platinum-containing chemotherapy, or d. within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy 9. Adult and pediatric patients with unresectable or metastatic, microsatellite instability-high (MSI-H) or mismatch repair deficient (dmmr) solid tumors that have progressed following prior treatment and who have no satisfactory alternative treatment options, or colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan 10. Patients with recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma whose tumors express PD-L1 [Combined Positive Score (CPS) 1] as determined by an FDA-approved test, with disease progression on or after two or more prior lines of therapy including fluoropyrimidine- and platinum-containing chemotherapy and if appropriate, HER2/neu-targeted therapy 11. Patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy whose tumors express PD-L1 (CPS 1) as determined by an FDA approved test Limitations of Use: Keytruda is not recommended for treatment of patients with PMBCL who require urgent cytoreductive therapy (3).
Subject: Keytruda Page: 3 of 9 The safety and effectiveness of Keytruda in pediatric patients with MSI-H central nervous system cancers have not been established (3). This indication is approved under accelerated approval based on tumor response rate and progression-free survival. An improvement in survival or disease-related symptoms has not yet been established. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials (3). This indication is approved under accelerated approval based on tumor response rate and durability of response. An improvement in survival or disease-related symptoms has not yet been established. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials (3). Clinically significant immune-mediated adverse reactions may occur with Keytruda therapy including pneumonitis, colitis, hepatitis, hypophysitis, nephritis, hyperthyroidism, and hypothyroidism. Based on the severity of the adverse reaction, Keytruda should be withheld or discontinued and corticosteroids administered. Patients should be monitored for signs and symptoms of pneumonitis, colitis, hypophysitis, thyroid disorders, and changes in liver and renal function. Keytruda may cause fetal harm when administered to a pregnant woman. Female patients of reproductive potential should be advised of the potential hazard to a fetus (3). Safety and effectiveness of Keytruda have been established in pediatric patients (3). Related Policies Bavencio, Imfinzi, Opdivo, Tecentriq Policy This policy statement applies to clinical review performed for pre-service (Prior Approval, Precertification, Advanced Benefit Determination, etc.) and/or post-service claims. Keytruda may be considered medically necessary in patients with unresectable or metastatic melanoma, for metastatic non-small cell lung cancer (NSCLC), for metastatic nonsquamous non-small cell lung cancer (NSCLC), for recurrent or metastatic head and neck squamous cell carcinoma (HNSCC), patients with refractory classical Hodgkin lymphoma (chl), for refractory primary mediastinal large B-cell lymphoma (PMBCL), advanced or metastatic urothelial carcinoma, microsatellite instability-high (MSI-H) or a mismatch repair deficient (dmmr) solid tumors, or recurrent locally advanced or metastatic gastric or gastroesophageal junction
Subject: Keytruda Page: 4 of 9 adenocarcinoma, or recurrent or metastatic cervical cancer; and if the conditions indicated below are met. Keytruda is considered investigational in patients with all other indications. Prior-Approval Requirements Diagnoses Patient must have ONE of the following: 1. Unresectable or metastatic melanoma 2. Metastatic non-small cell lung cancer (NSCLC) with ONE of the following: a. PD-L1 tumor expression with Tumor Proportion Score (TPS) 50% determined by a FDA-approved test i. Negative for EGFR or ALK tumor expression b. PD-L1 tumor expression with Tumor Proportion Score (TPS) 1% determined by a FDA-approved test with ONE of the following: i. Negative for EGFR or ALK tumor expression 1) Disease progression on or after platinum-containing chemotherapy ii. Positive EGFR or ALK tumor expression 2) Disease progression after targeted FDA-approved therapy 3. Metastatic nonsquamous non-small cell lung cancer (NSCLC) a. Used in combination with pemetrexed and carboplatin b. Negative for EGFR or ALK tumor expression 4. Recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) a. Disease progression on or after platinum-containing chemotherapy 5. Refractory classical Hodgkin lymphoma (chl) a. Patient has relapsed after 3 or more prior lines of therapy 6. Refractory primary mediastinal large B-cell lymphoma (PMBCL) a. Patient has relapsed after 2 or more lines of therapy
Subject: Keytruda Page: 5 of 9 7. Advanced or metastatic urothelial carcinoma with ONE of the following: a. Patient is NOT eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1 with combined positive score (CPS) 10 as determined by an FDA-approved test b. Patient is NOT eligible for any platinum-containing chemotherapy c. Disease progression during or following platinum-containing chemotherapy or within 12 months of neoadjuvant or adjuvant treatment with platinumcontaining chemotherapy 8. Microsatellite instability-high (MSI-H) or mismatch repair deficient (dmmr) cancers with ONE of the following: a. Solid tumors that have progressed following prior treatment and who have no satisfactory alternative treatment options i. NOT for use in pediatric patients with MSI-H central nervous system cancers b. Colorectal cancer that has progressed following treatment with fluoropyrimidine, oxaliplatin, and irinotecan AND the following for MSI-H or dmmr cancers: a. Diagnosis has to be confirmed by PCR-based assay genetic testing 9. Recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma a. PD-L1 tumor expression with combined positive score (CPS) 1 as determined by an FDA-approved test b. Disease progression on or after two or more prior lines of therapy including fluoropyrimidine- and platinum-containing chemotherapy and if appropriate, HER2/neu-targeted therapy 10. Recurrent or metastatic cervical cancer a. Disease progression on or after chemotherapy b. PD-L1 tumor expression with combined positive score (CPS) 1 as determined by an FDA-approved test Prior Approval Renewal Requirements Diagnoses Patient must have ONE of the following:
Subject: Keytruda Page: 6 of 9 1. Unresectable or metastatic melanoma 2. Metastatic non-small cell lung cancer (NSCLC) 3. Metastatic nonsquamous non-small cell lung cancer (NSCLC) 4. Recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) 5. Refractory classical Hodgkin lymphoma (chl) 6. Refractory primary mediastinal large B-cell lymphoma (PMBCL) 7. Advanced or metastatic urothelial carcinoma 8. Microsatellite instability-high (MSI-H) or mismatch repair deficient (dmmr) cancers a. NOT for use in pediatric patients with MSI-H central nervous system cancers 9. Recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma 10. Recurrent or metastatic cervical cancer AND the following: a. Prescriber agrees to discontinue treatment for any immune mediated adverse reaction (encephalitis, nephritis, rash, decreased renal function and endocrinopathies) or disease progression Policy Guidelines Pre - PA Allowance None Prior - Approval Limits Duration 6 months Prior Approval Renewal Limits Duration 12 months Rationale Summary Keytruda is a monoclonal antibody indicated for the treatment of patients with advanced or unresectable melanoma, metastatic non-small cell lung cancer (NSCLC), metastatic nonsquamous non-small cell lung cancer (NSCLC), recurrent or metastatic head and neck squamous cell carcinoma (HNSCC), refractory classical Hodgkin lymphoma (chl) who are no longer responding to other drugs, refractory primary mediastinal large B-cell lymphoma
Subject: Keytruda Page: 7 of 9 (PMBCL), locally advanced or metastatic urothelial carcinoma, recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma, microsatellite instability-high or mismatch repair deficient solid tumors that have progressed following prior treatments, and recurrent or metastatic cervical cancer with disease progression on or after chemotherapy. Clinically significant immune-mediated adverse reactions may occur with Keytruda therapy including pneumonitis, colitis, hepatitis, hypophysitis, nephritis, hyperthyroidism, and hypothyroidism. Based on the severity of the adverse reaction, Keytruda should be withheld or discontinued and corticosteroids administered. Keytruda may cause fetal harm when administered to a pregnant woman. Safety and effectiveness of Keytruda have been established in pediatric patients (1-4). Prior authorization is required to ensure the safe, clinically appropriate and cost-effective use of Keytruda while maintaining optimal therapeutic outcomes. References 1. NCCN Clinical Practice Guidelines in Oncology Melanoma (Version 2.2018). National Comprehensive Cancer Network, Inc. January 2018. 2. NCCN Clinical Practice Guidelines in Oncology Non-Small Cell Lung Cancer (Version 3.2018). National Comprehensive Cancer Network, Inc. February 2018. 3. Keytruda [package insert]. Whitehouse Station, NJ: Merck Sharp & Dohme Corp. August 2018. 4. Boland CR, Thibodeau SN, Hamilton SR, et al. A National Cancer Institute Workshop on Microsatellite Instability for cancer detection and familial predisposition: development of international criteria for determination of microstatellite instability in colorectal cancer. Cancer Res. 1998 Nov 15;58(22):5248-57 Policy History Date September 2014 December 2014 June 2015 October 2015 December 2015 Action New Policy Annual editorial review and reference update Annual editorial review Addition of Metastatic non-small cell lung cancer (NSCLC) if the patient has PD-L1 tumor expression determined by a FDA-approved test and has disease progression on or after platinum-containing chemotherapy; or the patient has EGFR or ALK tumor expression and has disease progression after FDA-approved therapy
Subject: Keytruda Page: 8 of 9 March 2016 June 2016 August 2016 September 2016 November 2016 December 2016 March 2017 June 2017 July 2017 September 2017 October 2017 December 2017 June 2018 July 2018 Removal of disease progression following Yervoy (ipilimumab) and, if BRAF V600 mutation positive, a BRAF inhibitor and no concurrent therapy with other agents for the treatment of unresectable or metastatic melanoma Annual editorial review Policy number change from 5.04.50 to 5.21.50 Annual editorial review Addition of Prescriber agrees to discontinue treatment for any immune mediated adverse reaction (encephalitis, nephritis, rash, decreased renal function and endocrinopathies) or disease progression in renewal section per SME Addition of recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) with disease progression on or after platinumcontaining chemotherapy Addition of (NSCLC) PD-L1 tumor expression with Tumor Proportion Score (TPS) 50% determined by a FDA-approved test with no prior treatment needed Addition of refractory classical Hodgkin lymphoma (chl), who have relapsed after 3 or more prior lines of therapy Removal of the age requirement Annual editorial review and reference update Addition of metastatic nonsquamous non-small cell lung cancer (NSCLC) Addition of advanced or metastatic urothelial carcinoma Addition of Microsatellite instability-high (MSI-H) or mismatch repair deficient (dmmr) cancers with additional requirements to criteria Addition of the requirement to MSI-H: diagnosis has to be confirmed by PCR-based genetic testing Addition of recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma Annual editorial review and reference update Addition of the diagnosis of recurrent or metastatic cervical cancer Addition of use of medication in patients with locally advanced or metastatic urothelial carcinoma in patients who are not eligible for any platinum-containing chemotherapy
Subject: Keytruda Page: 9 of 9 August 2018 September 2018 Addition of diagnosis of refractory primary mediastinal large B-cell lymphoma (PMBCL) Addition of no EGFR or ALK genomic tumor aberrations requirement to metastatic nonsquamos NSCLC Annual editorial review and reference update Keywords This policy was approved by the FEP Pharmacy and Medical Policy Committee on September 20, 2018 and is effective on October 1, 2018.