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Effective Date: 04/01/2019 Title: Lumoxiti
Revision Date: 10/01/2019 Document: BI609:00
CPT Code(s): C9045, J9313
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)    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.


Medical Statement

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.


Limits

1)    Limited to maximum of 6 cycles (28-day cycles as noted above).


Reference

1)    Lumoxiti Prescribing Information. AstraZeneca Pharmaceuticals LP. Wilmington, DE. September 2018.

2)    NCCN Drugs and Biologic Compendium. Accessed online 03-18-2019.


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.
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