| Effective Date:10/01/2014 |
Title:Sylvant (Siltuximab)
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| Revision Date:12/01/2016
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Document:BI459:00
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| CPT Code(s):J2860
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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.
1)
Sylvant is
used to treat multi-centric Castleman’s disease (MCD)
2)
Sylvant is
a specialty medication covered under the medical benefit.
3)
Sylvant (Siltuximab)
requires prior authorization.
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Medical Statement
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Sylvant is considered
medically necessary for members meeting the following criteria:
1)
Diagnosis
of multi-centric Castleman’s disease (MCD) AND
2)
Member is
human immunodeficiency virus (HIV) negative AND
3)
Member is
human herpesvirus-8 (HHV-8) negative
Reauthorization after 12 months will be provided if:
1)
Member is
HIV negative and HHV-8 negative AND
2)
Member has
not experienced treatment failure defines as disease progression based on
increase in symptoms, radiologic progression, or deterioration in performance
status.
Codes Used In This BI:
J2860 Siltuximab Injection, 10mg (code recycled/reinstated on 1/1/16)
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Limits
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Intentially left empty
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Reference
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1)
Sylvant
Prescribing Information. Janssen Biotech, Inc. June 2014
2)
Clinical
Pharmacology. Accessed online September 2014.
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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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