Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Food and Drug Administration (FDA) Indication
Belatacept (Nulojix) is considered medically necessary for prophylaxis of organ rejection in adult individuals receiving de novo kidney transplants when BOTH of the following criteria are met:
- Used in combination with basiliximab induction, mycophenolate mofetil, and corticosteroids; and
- Transplant recipients are Epstein-Barr virus (EBV) seropositive (i.e., having evidence of acquired immunity shown by the presence of IgG antibodies to viral capsid antigen [VCA] and EBV nuclear antigen [EBNA]).
The use of belatacept (Nulojix) for any other indication, including prophylaxis of organ rejection in transplanted organs other than kidney, is considered experimental/investigational and therefore, non-covered, due to lack of supporting published peer reviewed literature.
Procedure Codes
