| Effective Date:04/01/2019 |
Title:Lumoxiti
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| Revision Date:10/01/2019
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Document:BI609:00
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| CPT Code(s):C9045, J9313
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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)
Lumoxiti (moxetumomab
pasudotox) requires prior authorization.
2)
Lumoxiti is
used to treat hairy-cell leukemia.
3)
Lumoxiti is
a specialty drug covered under the medical benefit.
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Medical Statement
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Lumoxiti (moxetumomab pasudotox) is considered medically necessary for patients
meeting the following conditions:
1)
Patient is
18 years of age or older AND
2)
Patient has
a diagnosis of relapsed/refractory hairy-cell leukemia AND
3)
Patient has
received at least two (2) prior systemic therapies, including treatment with a
purine nucleoside analog (cladribine or pentostatin) AND
4)
Patient
does not have severe renal impairment defined as CrCl <29mL/min
Initial authorization is for a maximum of 6 cycles. Dosing is by IV infusion on
days 1, 2, and 5 of each 28-daycycle. May not be reauthorized after 6 cycles
received.
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Limits
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1)
Limited to
maximum of 6 cycles (28-day cycles as noted above).
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Reference
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1)
Lumoxiti
Prescribing Information. AstraZeneca Pharmaceuticals LP. Wilmington, DE.
September 2018.
2)
NCCN Drugs
and Biologic Compendium. Accessed online 03-18-2019.
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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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