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.
Elotuzumab (Empliciti) may be considered medically necessary for individuals 18 years of age and older for the treatment of multiple myeloma when the following criteria are met:
- Individual has received one (1) to three (3) prior therapies; and
- Elotuzumab (Empliciti) is being used in combination with lenalidomide and dexamethasone; or
- Individual has received at least two (2) prior therapies including lenalidomide and a proteasome inhibitor; and
- Elotuzumab (Empliciti) is being used in combination with pomalidomide and dexamethasone; or
Compendia Sources
Elotuzumab (Empliciti) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of elotuzumab (Empliciti) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Codes
