​Effective November 7, 2022, Independence Blue Cross and Independence Administrators will update their medical policy on Pemetrexed (Alimta^®), Pemetrexed (Pemfexy™) for both Commercial and Medicare Advantage members.

For Commercial and Medicare Advantage members, the medical necessity criteria will be revised to reflect the National Comprehensive Cancer Network (NCCN) compendia for Nonsquamous Non-Small Cell Lung Cancer (NSCLC) and Ovarian cancer, Fallopian Tube Cancer, and Peritoneal Cancer, including the additional indication of Malignant Peritoneal Mesothelioma (Sarcomatoid, Epithelioid, Biphasic, Benign Multicystic, Well-Differentiated Papillary) and Low-Grade Serous Carcinoma.

For both Commercial and Medicare Advantage members, the following ICD-10 codes will be removed from this policy:

• C34.00 Malignant neoplasm of unspecified main bronchus
• C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
• C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
• C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
• C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
• C56.9 Malignant neoplasm of unspecified ovary
• C57.00 Malignant neoplasm of unspecified fallopian tube
• C57.10 Malignant neoplasm of unspecified broad ligament
• C57.20 Malignant neoplasm of unspecified round ligament
• D15.0 Benign neoplasm of thymus

For Commercial members, the following ICD-10 codes will be added to this policy:

• C45.2 Mesothelioma of pericardium
• C45.7 Mesothelioma of other sites
• C45.9 Mesothelioma, unspecified

For Medicare Advantage members, the following ICD-10 codes will be added to this policy:

C17.0, C17.1, C17.2, C17.3, C17.8, C17.9, C18.0, C18.1, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20, C21.8, C45.2, C45.7, C45.9, C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122 C50.211, C50.212, C50.221, C50.222, C50.311, C50.312 C50.321, C50.322, C50.411, C50.412, C50.421, C50.422 C50.511, C50.512, C50.519, C50.521, C50.522, C50.611 C50.612, C50.621, C50.622, C50.811, C50.812, C50.821 C50.822, C50.911, C50.912, C50.921, C50.922, C53.0, C53.1, C53.8, C53.9, C64.1, C64.2, C65.1, C65.2, C67.0, C67.1, C67.2, C67.3, C67.4, C67.5, C67.6, C67.7, C67.8, C67.9, C76.0

For more information, please refer to the Commercial and Medicare Advantage policy notifications published on October 7, 2022.