Medical Policy
Effective Date:12/01/2016 Title:Empliciti (Elotuzumab)
Revision Date:06/01/2019 Document:BI519:00
CPT Code(s):C9477; J9176
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)    Empliciti (Elotuzumab) requires prior authorization.

2)    Empliciti is used to treat multiple myeloma.
Medical Statement

Empliciti (Elotuzumab) is considered medically necessary for patients meeting all of the following conditions:

1)    Diagnosis of multiple myeloma (C90.00, C90.02), AND

2)    Has received at least one prior treatment for multiple myeloma, AND

3)    Empliciti is being used in combination with Dexamethasone and Revlimid (Lenalidomide), OR

4)    Diagnosis of multiple myeloma (C90.00, C90.02), AND

5)    Has received at least 2 prior therapies including Revlimid (Lenalidomide) and a proteasome inhibitor (e.g.  Velcade, Kyprolis, Ninlaro), AND

6)    Used in combination with Pomalyst (Pomalidomide) and Dexamethasone.

Codes Used In This BI:

J9176     Injection, Elotuzumab, 1mg

Limits
Intentially left empty
Reference

1)    Empliciti Prescribing Information. Bristol Myers Squibb. Princeton, NJ. November 2015.

2)    Clinical Pharmacology. Accessed online 04/25/19.
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.