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Prior Authorization Required for Tarlatamab-dlle (Imdelltra) Effective November 1, 2024

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after November 1, 2024, prior authorization will be required for tarlatamab-dlle (Imdelltra), procedure code C9170.

Tarlatamab-dlle (Imdelltra) is a bispecific delta-like ligand 3 (DLL3)-directed CD3 T-cell engager indicated for the treatment of adult clients with extensive-stage small cell lung cancer (ES-SCLC) with disease progression on or after platinum-based chemotherapy.

Tarlatamab-dlle (Imdelltra) infusion must be administered by a qualified health care professional in a health care setting with appropriate medical support.

Prior Authorization Requirements for Tarlatamab-dlle (Imdelltra)

Prior authorization requests for tarlatamab-dlle (Imdelltra) must be submitted on the Special Medical Prior Authorization (SMPA) Request Form.

Requests for Initial Therapy

Initial therapy for tarlatamab-dlle (Imdelltra) may be approved if all the following criteria are met:

  • The client is 18 years of age or older.
  • The client has a confirmed diagnosis of ES-SCLC (diagnosis code C3400, C3401, C3402, C3410, C3411, C3412, C342, C3430, C3431, C3432, C3480, C3481, C3482, C3490, C3491, or C3492).
  • The client has previously received platinum-based chemotherapy (cisplatin or carboplatin).
  • The client does not have a clinically significant active systemic infection.
  • The prescriber attests to counseling female clients of childbearing age regarding the risk of embryo-fetal toxicity and counseling to prevent pregnancy during the treatment period and two months after the last infusion of tarlatamab-dlle (Imdelltra) by using an effective method of contraception.

Providers should monitor the client for signs and symptoms of:

  • Severe reactions such as cytokine release syndrome (CRS).
  • Neurologic toxicity, including immune effector cell-associated neurotoxicity syndrome (ICANS).
  • Cytopenia, including neutropenia, thrombocytopenia, and anemia. Providers should perform complete blood counts before each tarlatamab-dlle (Imdelltra) treatment.
  • Providers should monitor liver enzymes and bilirubin before each tarlatamab-dlle (Imdelltra) treatment.

Requests for Renewal or Continuation of Therapy

The client must meet the following requirements to renew or continue with tarlatamab-dlle (Imdelltra) therapy:

  • The client continues to meet the requirements listed above and has been treated with tarlatamab-dlle (Imdelltra) in the past.
  • The client experienced positive clinical response to treatment, as documented by stabilization of the disease, and a decrease in tumor size or spread.
  • The client has not experienced any unacceptable, clinically significant adverse reactions or toxicity (severe cytopenia, hepatotoxicity, or neurotoxicity) while on tarlatamab-dlle (Imdelltra) therapy.

For more information, call the TMHP Contact Center at 800-925-9126.