Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 02/03/2010 Title: Folotyn (Pralatrexate)
Revision Date: 04/01/2018 Document: BI259:00
CPT Code(s): J9307
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

  1. Folotyn (Pralatrexate) is an intravenous drug used to different types of leukemia and lymphoma.

Medical Statement

Folotyn (Pralatrexate) is covered for the following diagnoses:

a)    Peripheral T-cell Lymphomas (C84.40-C84.49, C84.60-C84.69, C84.70-C84.79, C86.2, C86.5, and Z85.72)

b)    T-Cell Lymphomas – Mycosis Fungoides/Sezary Syndrome (C84.00-84.09, C84.10-84.19)

c)    T-Cell Lymphomas – Primary Cutaneous CD30+ T-Cell Lymphoproliferative Disorders (C86.6, Z85.72)

d)    T-Cell Lymphomas – Adult T-Cell Leukemia/Lymphoma (C91.50, C91.52)

Codes Used In This BI:

J9307   Folotyn Inj, 1 mg


Limits

Folotyn is not covered for other uses.


Reference

Addendum:

Effective 01/01/2017: Added HCPCS code J9307 to BI.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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