Mogamulizumab-kpkc (Poteligeo ) is a defucosylated, humanized IgG1 kappa monoclonal antibody that binds to CCR4, a G protein-coupled receptor for CC chemokines that is involved in the trafficking of lymphocytes to various organs. CCR4 is expressed on the surface of some T-cell malignancies. Mogamulizumab-kpkc (Poteligeo) binding targets a cell for antibody-dependent cellular cytotoxicity and results in depletion of the target cells.
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
Mogamulizumab-kpkc (Poteligeo) may be considered medically necessary for the treatment of relapsed or refractory mycosis fungoides (MF) or Sezary syndrome (SS) after at least one prior systemic therapy when ALL of the following criteria are met:
National Comprehensive Cancer Network (NCCN) Recommendations
Mogamulizumab-kpkc (Poteligeo) may be considered medically necessary for ANY of the following conditions:
The use of mogamulizumab-kpkc (Poteligeo) for any other indication is considered experimental/investigational as the published peer reviewed literature does not support its efficacy or safety for any other indications.
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
Covered Diagnosis Codes