Carfilzomib (Kyprolis)

Section: Injections
Effective Date: December 01, 2019
Revised Date: November 26, 2019

Description

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.

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 for EITHER of the following cancers when the following criteria have been met:

Food and Drug Administration (FDA) Indication

Multiple Myeloma

  • In combination with dexamethasone or with lenalidomide 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) Indications

Multiple Myeloma

  • Primary therapy for active (symptomatic) myeloma or disease relapse after six (6) months following primary induction therapywith the same regimen in combination with:
    • Dexamethasone and lenalidomide; or
    • Dexamethasone and cyclophosphamide for non-transplant candidates; or
  • Therapy for previously treated myeloma for disease relapse or for progressive disease in combination with:
    • Dexamethasone (preferred regimen); or
    • Dexamethasone and lenalidomide; 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

Waldenström’s Macroglobulinemia/Lympholasmacytic Lymphoma

  • Used as a component of CaRD (carfilzomib, rituximab, and dexamethasone) regimen:
    • As a primary therapy; or
    • For relapse equal to or greater than 24 monthsif used as a primary therapy.

Carfilzomib (Kyprolis) for any other indication not listed in this policy is considered not medically necessary.

Procedure Codes

J9047

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

Diagnosis Codes

C83.00 C83.01 C83.02 C83.03 C83.04 C83.05 C83.06
C83.07 C83.08 C83.09 C88.0 C90.00 C90.02 C90.10
C90.12 C90.20 C90.22 C90.30 C90.32 Z85.72 Z85.79

Professional Statements and Societal Positions Guidelines

NA

Links