Coverage Policies

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INDEX:



Effective Date: 01/01/2021	Title: Monjuvi (tafasitamab-cxix)
Revision Date:	Document: BI676:00
CPT Code(s): C9070, J9349
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) Monjuvi (tafasitamab) requires prior authorization. 2) Monjuvi is used to treat a type of lymphoma. 3) Monjuvi is a specialty drug covered under the medical benefit.
Medical Statement
Monjuvi (tafasitamab-cxix) is considered medically necessary for members meeting the following criteria: Diffuse Large B-Cell Lymphoma (must meet all): 1) Diagnosis of relapsed or refractory DLBCL, including CLBCL arising from low grade lymphoma (e.g. follicular lymphoma or nodal marginal zone lymphoma); 2) Prescribed by or in consultation with an oncologist or hematologist; 3) Age >18 years; 4) Prescribed after prior therapy in combination with Revlimid (lenalidomide) for 12 cycles and subsequently as monotherapy; 5) Member is not eligible for ASCT; 6) Dose not exceed 12mg/kg as follows (a, b, and c): a. Cycle 1: Days 1, 4, 8, 15, and 22 of the 28-day cycle; b. Cycles 2 and 3: Days 1, 8, 15, and 22 of each 28-day cycle; c. Cycle 4 and beyond: Days 1 and 15 of each 28-day cycle Approval Duration: 6 months Reauthorization (12 months) approved if member responding positively to therapy incombination with Revlimid at same dosing outlined above. Codes Used In This BI: C9070 Injection, tafasitamab-cxix, 2 mg (deleted & replaced by code J9349 eff 04/01/2021) J9349 Injection, tafasitamab-cxix, 2 mg (new code eff 04/01/2021)
Reference
1) Monjuvi Prescribing Information. Boston, MA: Morphosys US, Inc.; July 2020. 2) NCCN Drugs and Biologics Compendium. Accessed online November 25, 2020. Addendum: 1) Effective 01-01-2021: New code C9070 2) Effective 04/01/2021: Deleted code C9070 & replaced by new code J9349
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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