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.
Motixafortide (Aphexda) is considered medically necessary when
ALL
of the following criteria are met:
-
Individual is 18 years of age or older;
and
-
Individual is diagnosed with multiple myeloma;
and
-
Used in combination with filgrastim;
and
-
Motixafortide will be used to mobilize hematopoietic stem cells for collection prior to autologous transplantation;
or
Compendia Sources
Motixafortide (Aphexda) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.
The use of motixafortide (Aphexda) 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.
Note:
Motixafortide (Aphexda) is to be prescribed under the supervision of an oncologist/hematologist.
Procedure Code
