Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Carfilzomib (Kyprolis) may be considered medically necessary when the following criteria have been met:
Multiple Myeloma
-
For the treatment of individuals with relapsed or refractory multiple myeloma who have received one to three lines of therapy in combination with
ANY
of the following:
-
Lenalidomide and dexamethasone;
or
-
Dexamethasone;
or
-
Daratumumab and dexamethasone;
or
-
Daratumumab and hyaluronidase-fihj and dexamethasone;
or
-
Isatuximab and dexamethasone;
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
Compendia Sources
Carfilzomib (Kyprolis) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
The use of carfilzomib (Kyprolis) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
