Background

Loqtorzi (toripalimab-tpzi) is a prescription medicine used to treat adults with a kind of cancer called nasopharyngeal carcinoma (NPC). It may be used in combination with chemotherapy medicines cisplatin and gemcitabine as first treatment for metastatic or recurrent NPC.

Policy (Criteria)

Loqtorzi is considered MEDICALLY NECESSARY for treatment of Advanced Nasopharyngeal Carcinoma when the following criteria are met:

1. 1. Diagnosis of NPC
   2. Prescribed by or in consultation with an oncologist
   3. Age ≥ 18 years
   4. Disease is unresectable, recurrent, or metastatic
   5. Loqtorzi is prescribed in one of the following ways (a or b):
      1. In combination with cisplatin and gemcitabine
      2. As a single agent for disease that has progressed on or after platinum-containing chemotherapy
   6. Member has not received prior treatment with an anti-PD-(L)1 antibody
   7. Request meets one of the following (a, b or c):
      1. In combination with cisplatin and gemcitabine: 240 mg every three weeks
      2. As a single agent for disease that has progressed on or after platinum-containing chemotherapy: 3 mg/kg intravenously every two weeks
      3. Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).

Approval duration: 6 months

Continuation of Loqtorzi is considered MEDICALLY NECESSARY when there is documentation that member is responsive to therapy with no disease progression.

Approval duration: 12 months

References

1. Loqtorzi (toripalimab) [prescribing information]. Redwood City, CA: Coherus BioSciences Inc; October 2024.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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