Medical Policy

Effective Date:01/01/2013 Title:Zaltrap
Revision Date:01/01/2017 Document:BI396:00
CPT Code(s):J9400
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)    Zaltrap is an intravenous drug used to treat metastatic colorectal cancer.

2)    Zaltrap is covered under the medical benefit as a specialty drug.

3)    Zaltrap (Ziv-Aflibercept) requires prior authorization.

Medical Statement

Zaltrap is considered medically necessary for patients who meet ALL of the following criteria:

1)    Diagnosis of metastatic colorectal cancer  AND

2)    Resistant to or progressed following an oxaliplatin-containing regimen AND

3)    Is used in combination with 5-fluorouracil, leucovorin and irinotecan (FOLFIRI).


Codes Used In This BI:


J9400   Ziv-Aflibercept Injection, 1mg

Intentially left empty

1)    Zaltrap Product Information. Sanofi Aventis.  Bridgewater, NJ; August 2012

2)    National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Colon Cancer / Rectal Cancer v.1.2013

3)    Zaltrap.  Clinical Pharmacology.  Accessed online January 2013.


Effective 01/01/2017: Removed HCPCS Code C9296 from Claim Statement & Codes Used In This BI section. This code is no longer valid effective 1/1/14.

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.