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.
Carfilzomib (Kyprolis) may be considered medically necessary when used for ANY of the following:
Food and Drug Administration (FDA) Indications
Multiple Myeloma
- In combination with dexamethasone or with lenalidomide plus dexamethasone or with daratumumab plus dexamethasone for the treatment of individuals with relapsed or refractory multiple myeloma who have received one to three lines of therapy; or
- As a single agent for the treatment of individuals with relapsed or refractory multiple myeloma who have received one or more lines of therapy; or
National Comprehensive Cancer Network (NCCN) Recommendations
Multiple Myeloma
- Primary therapy for active (symptomatic) myeloma or disease relapse after six (6) months following primary induction therapy with the same regimen in combination with:
- Dexamethasone and lenalidomide; or
- Dexamethasone and cyclophosphamide for individuals with renal insufficiency and/or peripheral neuropathy; or
- Therapy for previously treated myeloma for disease relapse or for progressive disease in combination with:
- Dexamethasone; or
- Dexamethasone and lenalidomide (preferred** regimen); or
- Dexamethasone and daratumumab (preferred** regimen); or
- Dexamethasone and cyclophosphamide; or
- Pomalidomide and dexamethasone in individuals who have received at least two (2) prior therapies, including an immunomodulatory agent and a proteasome inhibitor, and have demonstrated disease progression on or within 60 days of completion of the last therapy; or
- Panobinostat in individuals who have received at least two (2) prior regimens, including bortezomib and an immunomodulatory agent; or
- Dexamethasone, cyclophosphamide and thalidomide; or
Waldenström’s Macroglobulinemia/Lympholasmacytic Lymphoma
- Used as a component of CaRD (carfilzomib, rituximab, and dexamethasone) regimen:
- As a primary therapy; or
- For relapse if previously used as a primary therapy that was well tolerated and elicited a prolonged response.
Carfilzomib (Kyprolis) for any other indication not listed in this policy is considered not medically necessary.
Procedure Codes
