| Effective Date:01/01/2024 |
Title:Aphexda
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| Revision Date:
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Document:BI728:00
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| CPT Code(s):
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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)
Aphexda (motixafortide)
requires prior authorization.
2)
Aphexda is used to
mobilize hematopoietic stem cells in combination with filgrastim.
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Medical Statement
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Initial Approval Criteria
I.
Mobilization of
Hematopoietic Stem Cell (must meet all):
a.
Diagnosis of Multiple
Myeloma (MM);
b.
Prescribed by or in
consultation with an oncologist or hematologist;
c.
Age > 18 years:
d.
Prescribed in combination
with a formulary G-CSF
e.
Member is scheduled to
receive autologous stem cell transplantation;
f.
Dose is consistent with
FDA-labeling
Approval Duration: 3 months
Reauthorization Requests must meet initial approval criteria.
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Limits
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Intentially left empty
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Reference
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1.
Aphexda Prescribing
Information. Waltham, MA: BioLineRx; September 2023. Available at:
www.aphexda.com.
Accessed September 13, 2023.
2.
National Comprehensive Cancer Network Drugs and Biologics
Compendium. Available at:
https://www.nccn.org/professionals/drug_compendium/content/. Accessed September
29, 2023.
3.
National Comprehensive Cancer Network. Multiple Myeloma Version
1.2024. Available at:
https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf. Accessed
September 29, 2023.
4.
National Comprehensive Cancer Network. Hematopoietic Cell
Transplantation Version 2.2023. Available at:
https://www.nccn.org/professionals/physician_gls/pdf/hct.pdf. Accessed September
29, 2023.
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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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