| Effective Date:01/01/2019 |
Title:Poteligeo (mogamulizumab)
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| Revision Date:10/01/2019
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Document:BI596:00
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| CPT Code(s):C9038, J9204
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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)
Poteligeo (mogamulizumab)
requires prior authorization.
2)
Poteligeo
is used to treat rare forms of non-Hodgkin’s lymphoma (NHL).
3)
Poetligeo
is considered a specialty drug and is covered under the medical benefit.
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Medical Statement
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Poteligeo (mogamulizumab) is considered medically necessary for patients meeting
the following conditions:
1)
Patient is
18 years of age or older AND
2)
Diagnosis
of cutaneous T-cell lymphoma (CTCL), specifically Stage IB-IV mycosis fungoides
or Sezary Syndrome AND
3)
Patient has
received at least one (1) prior systemic therapy AND
4)
If
previously treated with an antiCD4 antibody or alemtuzumab, CD4+ cell counts
must be > 200/mm3 .
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Limits
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Intentially left empty
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Reference
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1)
Poteligeo
Package Insert. Kyowa Kirin, Inc. August 2018
2)
Clinical
Pharmacology. Accessed online November 5, 2018.
3)
Kim YH,
Bagot M, Pinter-Brown L, et al. Study of KW-0761 versus vorinostat in
relapsed/refractory CTCL. Lancet Oncol. 2018; doi:
10.1016/S1470-2045(18)30379-6
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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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