Pharmacy Prior Authorization Criteria

Opdualag (nivolumab and relatlimab-rmbw)

Indications for Prior Authorization

Opdualag (nivolumab and relatlimab-rmbw)

• For diagnosis of Metastatic Melanoma
  Indicated for the treatment of adult and pediatric patients 12 years of age or older with unresectable or metastatic melanoma.

Criteria

Opdualag

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• One of the following diagnoses:
• Unresectable melanoma
• Metastatic melanoma
AND
• Both of the following:
• Patient is 12 years of age or older
• Patient weighs at least 40 kg (88 lbs)

Opdualag

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient does not show evidence of progressive disease while on therapy

P & T Revisions

2024-05-01, 2023-07-03, 2023-05-03, 2022-05-05

References

1. Opdualag Prescribing Information. Bristol-Myers Squibb. Princeton, NJ. March 2024.

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Revision History

• 2024-05-01: Annual review - no criteria changes; background update
• 2023-07-03: Removed specialist requirement
• 2023-05-03: Annual review - no criteria changes
• 2022-05-05: New program

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