Elotuzumab (Empliciti) (Medicaid Expansion)

Policy ID: ME-I-166-008-01

Section: Injections

Effective Date: December 09, 2024

Last Reviewed: November 19, 2024

Applies To: Medicaid Expansion Only

Description

Elotuzumab (Empliciti®) is a humanized IgG1 monoclonal antibody that specifically targets the Signaling Lymphocytic Activation Molecule Family member 7 (SLAMF7) protein, which is present on myeloma cells and natural killer cells.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

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, 2A, or 2B NCCN recommendations.

The use of elotuzumab (Empliciti) 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

J9176

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

C90.00

C90.02

C90.10

C90.12

C90.20

C90.22

C90.30

C90.32

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2024 Effective December 09, 2024

Adopted Medicaid Expansion specific policy

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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