Carfilzomib (Kyprolis®) is a targeted therapy drug and is classified as a Proteasome Inhibitor. It is used in the treatment of Multiple Myeloma (MM) and Waldenström’s Macroglobulinemia/Lympholasmacytic Lymphoma.
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 for EITHER of the following cancers when the following criteria have been met:
Food and Drug Administration (FDA) Indication
National Comprehensive Cancer Network (NCCN) Indications
Waldenström’s Macroglobulinemia/Lympholasmacytic Lymphoma
Carfilzomib (Kyprolis) for any other indication not listed in this policy is considered not medically necessary.
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits