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.
U.S. Food and Drug Administration (FDA) Indications
Elotuzumab (Empliciti) may be considered medically necessary for individuals 18 years of age and older when the following criteria are met:
- Therapy for multiple myeloma; and
- Individual has received one to three 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 pamalidomide and dexamethasone.
National Comprehensive Cancer Network (NCCN) Recommendations
Multiple Myeloma
Elotuzumab (Empliciti) may be considered medically necessary for individuals 18 years of age and older when the following criteria are met:
- Therapy for previously treated myeloma for relapse or progressive disease in combination with:
- Lenalidomide and dexamethasone in individuals who have received one to three prior therapies (preferred regimen*); or
- Bortezomib and dexamethasone; or
- Pomalidomide and dexamethasone in individuals who have received at least two prior therapies, including an immunomodulatory agent and a proteasome inhibitor.
Elotuzumab (Empliciti) is considered experimental/investigational for any other indication and therefore non-covered. Scientific evidence does not support its use for any other indications.
Procedure Codes
