Medical Policy

Effective Date:01/01/2019 Title:Poteligeo (mogamulizumab)
Revision Date:10/01/2019 Document:BI596:00
CPT Code(s):C9038, J9204
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)    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.

Medical Statement

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 .

Limits
Intentially left empty
Reference

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

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.