Pharmacy Prior Authorization Criteria

Kimmtrak (tebentafusp-tebn)

Indications for Prior Authorization

Kimmtrak (tebentafusp-tebn) injection, for intravenous use

• For diagnosis of Uveal Melanoma
  Indicated for the treatment of HLA-A*02:01-positive adult patients with unresectable or metastatic uveal melanoma.

Criteria

Kimmtrak

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of uveal melanoma
AND
• Disease is unresectable or metastatic
AND
• Patient is HLA-A*02:01 genotype positive as determined by a high-resolution genotyping test [2]

Kimmtrak

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

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

P & T Revisions

2024-04-02, 2023-07-31, 2023-03-13, 2022-02-24

References

1. Kimmtrak Prescribing Information. Immunocore Commercial LLC. Conshohocken, PA. January 2022.
2. Nunes E, Heslop H, Fernandez-Vina M, et al. Definitions of histocompatibility typing terms. Blood. 2011;118(23):e180-e183.

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Revision History

• 2024-04-02: Annual Review
• 2023-07-31: Removed specialist requirement
• 2023-03-13: Annual Review - no criteria changes
• 2022-02-24: New UM Program

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