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.
Food and Drug Administration (FDA) Indications:
Moxetumomab pasudotox-tdfk (Lumoxiti) may be considered medically necessary in adult individuals who meet ALL of the following criteria:
- Diagnosis of relapsed or refractory hairy cell leukemia (HCL); and
- Previously treated with at least two (2) prior systemic therapies, including one PNA
National Comprehensive Cancer Network (NCCN) Recommendations:
Moxetumomab pasudotox-tdfk (Lumoxiti) may be considered medically necessary in adult individuals for treatment as a single agent for progression of HCL after therapy for relapsed/refractory disease.
Moxetumomab pasudotox-tdfk (Lumoxiti) for the treatment of any other indication is considered experimental/investigational; there is a lack of scientific documentation supporting its use for any other indication.
Procedure Codes
