Medical Policy

Effective Date:04/01/2012 Title:Halaven (Eribulin)
Revision Date:01/01/2017 Document:BI346:00
CPT Code(s):J9179
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)    Halaven (Eribulin) requires prior authorization.

2)    Halaven is considered a specialty medication.

3)    Halaven is used to treat patients with metastatic breast cancer and soft tissue sarcomas.

Medical Statement

Halaven is considered medically necessary for members who meet the following criteria:

1)    Diagnosis of metastatic breast cancer  (C50.011-C50.929)


2)    Have previously received at least two (2) chemotherapeutic regimens for the treatment of metastatic disease including an anthracycline (doxorubicin or epirubicin) and a taxanes (docetaxel or paclitaxel). OR

3)    Diagnosis of soft tissue sarcoma, including angiosarcoma, retroperitoneal/intra-abdominal, rhabdomyosarcoma and sarcoma of the extremity/superficial trunk, head/neck.


Codes Used In This BI:


J9179           Eribulin mesylate injection

Intentially left empty

1)    Halaven Product Information.  EISAI.  November 2010.

2)    Clinical Pharmacology Online. “Eribulin”, retrieved December 2011.

3)    NCCN Drugs and Biologic Compendium.  Accessed online November 22, 2016.


Effective 01/01/2017: Updated approved diagnoses of soft tissue sarcomas.

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.