| Effective Date:02/03/2010 |
Title:Folotyn (Pralatrexate)
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| Revision Date:04/01/2018
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Document:BI259:00
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| CPT Code(s):J9307
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Public Statement
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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.
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Folotyn (Pralatrexate)
is an intravenous drug used to different types of leukemia and lymphoma.
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Medical Statement
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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
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Limits
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Folotyn is not covered for other uses.
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Reference
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Addendum:
Effective 01/01/2017: Added HCPCS code J9307 to BI.
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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