Last Review Date: 09/04/2025

Date of Origin: 06/24/2014

Dates Reviewed: 09/2014, 01/2015, 05/2015, 11/2015, 04/2016, 08/2016, 11/2016, 05/2017, 08/2017, 11/2017, 02/2018, 05/2018, 09/2018, 12/2018, 03/2019, 06/2019, 09/2019, 12/2019, 03/2020, 06/2020, 09/2020, 12/2020, 03/2021, 06/2021, 09/2021, 12/2021, 03/2022, 06/2022, 09/2022, 12/2022, 03/2023, 06/2023, 09/2023, 12/2023, 03/2024, 09/2025

1. Length of Authorization

• Initial: Prior authorization validity will be provided initially for 6 months.
• Renewal: Prior authorization validity may be renewed every 6 months thereafter.

2. Dosing Limits

Max Units (per dose and over time) [HCPCS Unit]:

3. Initial Approval Criteria ¹

Prior authorization validity is provided in the following conditions:

• Patient is at least 18 years of age; AND

Universal Criteria ¹

• Patient does not have uncontrolled severe hypertension; AND
• Patient must not have had a surgical procedure within the preceding 2 weeks or have a surgical wound that has not fully healed; AND

Colorectal Cancer (CRC) ¥ † ‡ ^{1,3,9-11,17,18}

• Used in combination with irinotecan or FOLFIRI (irinotecan, folinic acid/leucovorin, and fluorouracil); AND
  • Used as initial treatment for unresectable metastatic disease after previous FOLFOX (fluorouracil, folinic acid/leucovorin, and oxaliplatin) or CapeOX (capecitabine and oxaliplatin) within the past 12 months ‡; OR
  • Used as subsequent therapy for progression of advanced or metastatic disease; AND
    • Patient has not previously been treated with irinotecan-based therapy

¥ Note: NCCN recommends universal MMR or MSI testing in all newly diagnosed patients. If deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) or polymerase epsilon/delta (POLE/POLD1) mutation with ultra-hypermutated phenotype (e.g., TMB>50 mut/Mb), treatment should include checkpoint inhibitor immunotherapy if the patient is a candidate.

Appendiceal Adenocarcinoma – Colon Cancer ¥ ‡ ³

• Used as subsequent therapy in combination with irinotecan or FOLFIRI (fluorouracil, leucovorin, and irinotecan) for progression of advanced or metastatic disease; AND
• Patient has not previously been treated with irinotecan-based therapy or with oxaliplatin

¥ Note: NCCN recommends universal MMR or MSI testing in all newly diagnosed patients. If deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) or polymerase epsilon/delta (POLE/POLD1) mutation with ultra-hypermutated phenotype (e.g., TMB>50 mut/Mb), treatment should include checkpoint inhibitor immunotherapy if the patient is a candidate.

Gastric, Esophageal, and Esophagogastric/Gastroesophageal Junction Cancers † ‡ Ф ^{1-3,5-7,14,15}

• Patient has adenocarcinoma histology; AND
• Used as subsequent therapy; AND

• Used as a single agent OR in combination with paclitaxel OR in combination with an irinotecan-based regimen; AND
  • Patient has advanced, recurrent, or metastatic disease; OR
  • Patient is not a surgical candidate

Hepatocellular Carcinoma (HCC) † ‡ Ф ^1,3,4,16

• Used as a single agent; AND
• Used as subsequent therapy for progressive disease; AND
• Patient has an alfa-fetoprotein (AFP) level of ≥ 400 ng/mL; AND
• Patient has Child-Pugh Class A hepatic impairment (i.e., excludes class B and C impairments)

Non-Small Cell Lung Cancer (NSCLC) † ‡ ^1,3,8,12,13

• Patient has recurrent, advanced, or metastatic disease (excluding locoregional recurrence or symptomatic local disease without evidence of disseminated disease) or mediastinal lymph node recurrence with prior radiation therapy; AND
  • Used in combination with docetaxel; AND

• • Used as subsequent therapy for first progression after initial systemic therapy; AND
  • Patient has not previously been treated with docetaxel or ramucirumab; OR

• • Used in combination with erlotinib; AND
    • Patient has epidermal growth factor receptor (EGFR) exon 19 deletion or exon 21 (L858R) substitution mutation positive disease as detected by an FDA-approved or CLIA compliant testv; AND

• • • Used as first-line therapy; OR
    • Used for continuation of therapy following disease progression on combination erlotinib and ramucirumab therapy for asymptomatic disease, symptomatic brain lesions, or symptomatic systemic limited progression; AND
      • Patient has T790M negative disease

Pleural Mesothelioma (PM)* ‡ ^3,19,20

• Used in combination with gemcitabine as subsequent therapy

*Note: May also be used for pericardial mesothelioma and tunica vaginalis testis mesothelioma.

Thymic Carcinoma ‡ ^3,21,22

• Used in combination with carboplatin and paclitaxel^ʌ; AND
  • Used as preoperative therapy for surgically resectable disease if R0 resection is considered uncertain; OR
  • Used as postoperative therapy after R1 (microscopic residual tumor) or R2 (macroscopic residual tumor) resection; OR
  • Used as first-line therapy for recurrent, advanced, or metastatic disease

^ʌRamucirumab may be continued as maintenance monotherapy

v If confirmed using an immunotherapy assay – http://www.fda.gov/companiondiagnostics

† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug

4. Renewal Criteria ^1,3,13

Prior authorization validity may be renewed based upon the following criteria:

• Patient continues to meet the universal and other indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
• Disease response with treatment as defined by stabilization of disease or decrease in size of tumor or tumor spread, unless otherwise specified in section III; AND
• Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: hemorrhage, arterial thromboembolic events, uncontrolled hypertension, infusion-related reactions, severe proteinuria (> 3g/24h), nephrotic syndrome, gastrointestinal perforations, impaired wound healing, posterior reversible encephalopathy syndrome (PRES), thyroid dysfunction, worsening of pre-existing hepatic impairment, etc.

5. Dosage/Administration ^{1,13-15,17,18,20-22}
6. Billing Code/Availability Information

HCPCS Code:

• J9308 − Injection, ramucirumab, 5 mg; 1 billable unit = 5 mg

NDC(s):

• Cyramza 100 mg/10 mL solution, single-dose vial: 00002-7669-xx
• Cyramza 500 mg/50 mL solution, single-dose vial: 00002-7678-xx

7. References

1. Cyramza [package insert]. Indianapolis, IN; Eli Lilly and Company; April 2025. Accessed August 2025.
2. Fuchs CS, Tomasek J, Yong CJ, et al.  Ramucirumab monotherapy for previously treated advanced gastric or gastro-esophageal junction adenocarcinoma (REGARD): an international, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet. 2014 Jan 4; 383(9911):31-9. doi: 10.1016/S0140-6736(13)61719-5. Epub 2013 Oct 3.
3. Referenced with permission from the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for ramucirumab. National Comprehensive Cancer Network, 2025. The NCCN Compendium^® is a derivative work of the NCCN Guidelines^®. NATIONAL COMPREHENSIVE CANCER NETWORK^®, NCCN^®, and NCCN GUIDELINES^® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed August 2025.
4. Zhu AX, Kang YK, Yen CJ, et al. REACH-2: A randomized, double-blind, placebo-controlled phase 3 study of ramucirumab versus placebo as second-line treatment in patients with advanced hepatocellular carcinoma (HCC) and elevated baseline alpha-fetoprotein (AFP) following first-line sorafenib. J Clin Oncol 2018;36:4003.
5. De Vita F, Borg C, Farina G, et al. Ramucirumab and paclitaxel in patients with gastric cancer and prior trastuzumab: subgroup analysis from RAINBOW study. Future Oncol. 2019 Aug;15(23):2723-2731. doi: 10.2217/fon-2019-0243. Epub 2019 Jun 25.
6. Shitara K, Muro K, Shimada Y, et al. Subgroup analyses of the safety and efficacy of ramucirumab in Japanese and Western patients in RAINBOW: a randomized clinical trial in second-line treatment of gastric cancer. Gastric Cancer. 2016 Jul;19(3):927-38. doi: 10.1007/s10120-015-0559-z. Epub 2015 Oct 28.
7. Wilke H, Muro K, Van Cutsem E, et al. Ramucirumab plus paclitaxel versus placebo plus paclitaxel in patients with previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma (RAINBOW): a double-blind, randomised phase 3 trial. Lancet Oncol. 2014 Oct;15(11):1224-35. doi: 10.1016/S1470-2045(14)70420-6. Epub 2014 Sep 17.
8. Garon EB, Ciuleanu TE, Arrieta O, et al. Ramucirumab plus docetaxel versus placebo plus docetaxel for second-line treatment of stage IV non-small-cell lung cancer after disease progression on platinum-based therapy (REVEL): a multicentre, double-blind, randomised phase 3 trial. Lancet. 2014 Aug 23;384(9944):665-73. doi: 10.1016/S0140-6736(14)60845-X. Epub 2014 Jun 2.
9. Yoshino T, Portnoy DC, Obermannová R, et al. Biomarker analysis beyond angiogenesis: RAS/RAF mutation status, tumour sidedness, and second-line ramucirumab efficacy in patients with metastatic colorectal carcinoma from RAISE-a global phase III study. Ann Oncol. 2019 Jan 1;30(1):124-131. doi: 10.1093/annonc/mdy461.
10. Obermannová R, Van Cutsem E, Yoshino T, et al. Subgroup analysis in RAISE: a randomized, double-blind phase III study of irinotecan, folinic acid, and 5-fluorouracil (FOLFIRI) plus ramucirumab or placebo in patients with metastatic colorectal carcinoma progression. Ann Oncol. 2016 Nov;27(11):2082-2090. Epub 2016 Aug 29.
11. Tabernero J, Yoshino T, Cohn AL, et al. Ramucirumab versus placebo in combination with second-line FOLFIRI in patients with metastatic colorectal carcinoma that progressed during or after first-line therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine (RAISE): a randomised, double-blind, multicentre, phase 3 study. Lancet Oncol. 2015 May;16(5):499-508. doi: 10.1016/S1470-2045(15)70127-0. Epub 2015 Apr 12.
12. Nakagawa K, Garon EB, Seto T, et al. Ramucirumab plus erlotinib in patients with untreated, EGFR-mutated, advanced non-small-cell lung cancer (RELAY): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Oncol. 2019 Dec;20(12):1655-1669. doi: 10.1016/S1470-2045(19)30634-5. Epub 2019 Oct 4.
13. Referenced with permission from the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Non-Small Cell Lung Cancer, Version 8.2025. National Comprehensive Cancer Network, 2025. The NCCN Compendium^® is a derivative work of the NCCN Guidelines^®. NATIONAL COMPREHENSIVE CANCER NETWORK^®, NCCN^®, and NCCN GUIDELINES^® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed August 2025.
14. Referenced with permission from the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Gastric Cancer, Version 2.2025. National Comprehensive Cancer Network, 2025. The NCCN Compendium^® is a derivative work of the NCCN Guidelines^®. NATIONAL COMPREHENSIVE CANCER NETWORK^®, NCCN^®, and NCCN GUIDELINES^® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed August 2025.
15. Referenced with permission from the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Esophageal and Esophagogastric Junction Cancers, Version 3.2025. National Comprehensive Cancer Network, 2025. The NCCN Compendium^® is a derivative work of the NCCN Guidelines^®. NATIONAL COMPREHENSIVE CANCER NETWORK^®, NCCN^®, and NCCN GUIDELINES^® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed August 2025.
16. Referenced with permission from the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Hepatocellular Carcinoma, Version 1.2025. National Comprehensive Cancer Network, 2025. The NCCN Compendium^® is a derivative work of the NCCN Guidelines^®. NATIONAL COMPREHENSIVE CANCER NETWORK^®, NCCN^®, and NCCN GUIDELINES^® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed August 2025.
17. Referenced with permission from the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Colon Cancer, Version 4.2025. National Comprehensive Cancer Network, 2025. The NCCN Compendium^® is a derivative work of the NCCN Guidelines^®. NATIONAL COMPREHENSIVE CANCER NETWORK^®, NCCN^®, and NCCN GUIDELINES^® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed August 2025.
18. Referenced with permission from the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Rectal Cancer, Version 2.2025. National Comprehensive Cancer Network, 2025. The NCCN Compendium^® is a derivative work of the NCCN Guidelines^®. NATIONAL COMPREHENSIVE CANCER NETWORK^®, NCCN^®, and NCCN GUIDELINES^® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed August 2025.
19. Referenced with permission from the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Mesothelioma: Pleural, Version 2.2025. National Comprehensive Cancer Network, 2025. The NCCN Compendium^® is a derivative work of the NCCN Guidelines^®. NATIONAL COMPREHENSIVE CANCER NETWORK^®, NCCN^®, and NCCN GUIDELINES^® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed August 2025.
20. Pinto C, Zucali PA, Pagano M, et al. Gemcitabine with or without ramucirumab as second-line treatment for malignant pleural mesothelioma (RAMES): a randomised, double-blind, placebo-controlled, phase 2 trial. Lancet Oncol. 2021 Oct;22(10):1438-1447. doi: 10.1016/S1470-2045(21)00404-6. Epub 2021 Sep 6. PMID: 34499874.
21. Referenced with permission from the NCCN Drugs and Biologics Compendium (NCCN Compendium^®) for Thymomas and Thymic Carcinomas, Version 2.2025. National Comprehensive Cancer Network, 2025. The NCCN Compendium^® is a derivative work of the NCCN Guidelines^®. NATIONAL COMPREHENSIVE CANCER NETWORK^®, NCCN^®, and NCCN GUIDELINES^® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed August 2025.
22. Proto C, Ganzinelli M, Manglaviti S, et al. Efficacy and safety of ramucirumab plus carboplatin and paclitaxel in untreated metastatic thymic carcinoma: RELEVENT phase II trial (NCT03921671). Ann Oncol 2024;35:817-826.

Appendix A – Non-Quantitative Treatment Limitations (NQTL) Factor Checklist

Non-quantitative treatment limitations (NQTLs) refer to the methods, guidelines, standards of evidence, or other conditions that can restrict how long or to what extent benefits are provided under a health plan. These may include things like utilization review or prior authorization. The utilization management NQTL applies comparably, and not more stringently, to mental health/substance use disorder (MH/SUD) Medical Benefit Prescription Drugs and medical/surgical (M/S) Medical Benefit Prescription Drugs. The table below lists the factors that were considered in designing and applying prior authorization to this drug/drug group, and a summary of the conclusions that Prime’s assessment led to for each.

Appendix 1 – Covered Diagnosis Codes

Appendix 2 – Centers for Medicare and Medicaid Services (CMS)

The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.

Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD/LCA): N/A