Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

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Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 06/01/2020	Title: Sarclisa
Revision Date: 08/01/2022	Document: BI655:00
CPT Code(s): J9227
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) Sarclisa (isatuximab) requires prior authorization. 2) Sarclisa is used to treat multiple myeloma who have failed other treatments. 3) Sarclisa is considered a specialty drug and covered under the medical benefit.
Medical Statement
Sarclisa (isatuximab-irfc) is considered medically necessary for members 18 years of age or older who meet the following criteria: 1) Diagnosis of multiple myeloma; 2) Have received at least two other therapies, including Revlimid and a proteasome inhibitor (e.g. Velcade, Ninlaro, Kyprolis) and will be used in combination with Pomalyst and dexamethasone; 3) Have received 1 to 3 prior lines of therapy and used in combination with carfilzomib and dexamethasone for relapsed or refractory disease; 4) Prescribed by or in consultation with an oncologist. Approval Duration: 6 months
Reference
1) Sarclisa Prescribing Information. Bridgewater, NJ: Sanofi-Aventis. March 2021. 2) Clinical Pharmacology. Accessed online 05-23-2022. 3) NCCN Drugs & Biologics Compendium. Accessed online 05-23-2022. Addendum: 1) Effective 10-01-2020: Removed restriction if Darzalex previously used. 2) Effective 08/01/2022: Updated to add criteria for use with carfilzomib and dexamethasone
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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