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.
Epcoritamab-bysp (Epkinly) may be considered medically necessary in adult individuals for the following conditions:
- For the treatment of relapsed or refractory diffuse large B-cell lymphoma (DLBCL) not otherwise specified (including DLBCL arising from indolent lymphoma) and high-grade B-cell lymphoma after two or more lines of systemic therapy; or
Compendia Sources
- Epcoritamab-bysp (Epkinly) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of epcoritamab-bysp (Epkinly) 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.
