OHS Formulary Restricted:

• Indication: treatment of adult patients with FRα positive, platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer, who have received one to three prior systemic treatment regimens
• Service line: gynecologic oncology
• Formulary location: outpatient infusion
• Service location: outpatient infusion, home infusion
• Patient population: female adults (≥18 years of age)
• Prior authorization required: yes
• Restriction/criteria of use (all will apply unless specified):
  • Confirmed diagnosis of high-grade serous epithelial ovarian cancer, primary peritoneal cancer, or fallopian tube cancel
  • Received at least one prior systemic line of anticancer therapy
  • Patient's tumor is positive for FRα expression as defined by the Ventana FOLR1 (FOLR-2.1) RxDx Assay
  • ECOG performance status of 0 or 1
  • Females of reproductive potential: negative pregnancy test prior to initiating therapy and use effective contraception during treatment and for 7 months after the last dose

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