Medical Policy

Effective Date:01/01/2016 Title:Farydak (Panobinostat)
Revision Date: Document:BI489:00
CPT Code(s):None
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)    Farydak (panobinostat) requires prior authorization.

2)    Farydak is used to treat relapsed multiple myeloma.

3)    Farydak is covered under the pharmacy benefit as a specialty drug.

Medical Statement

Farydak (Panobinostat) is considered medically necessary when the following criteria are met:


1)    Diagnosis of relapsed multiple myeloma (C90.02) AND

2)    Patient has received at least two prior therapies, including Bortezomib and an Immunomodulatory agent  AND

3)    Will be used with Bortezomib and Dexamethasone

Intentially left empty

1)    Farydak Prescribing Information.  Novartis Pharmaceuticals Corp. East Hanover, NJ. February 2015.

2)    Clinical Pharmacology. Accessed online 9/11/2015.

3)    NCCN Drugs & Biologics Compendium. Panobinostat. Accessed online 9/11/2015.

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.