Pralatrexate (FolotynTM) is a cytotoxic neoplastic agent, which acts as a folate analogue metabolic inhibitor leading to interruption of DNA synthesis. It competitively inhibits dihydrofolate reductase, and is a competitive inhibitor for polyglutamylation via the folylpolyglutamyl synthetase enzyme. This results in thymidine and other biological molecule depletion, the synthesis of which depends on single carbon transfer.
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.
Pralatrexate (Folotyn) may be considered medically necessary for ANY of the following indications:
Food and Drug Administration (FDA) Indications
National Comprehensive Cancer Network (NCCN) Indications
The use of pralatrexate (Folotyn) for any other indication is considered experimental/investigational and therefore, not covered. Scientific evidence does not support its use for any other indications.
Procedure Codes
J9307 |
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.
Diagnosis Codes
C84.00 | C84.01 | C84.02 | C84.03 | C84.04 | C84.05 | C84.06 |
C84.07 | C84.08 | C84.09 | C84.10 | C84.11 | C84.12 | C84.13 |
C84.14 | C84.15 | C84.16 | C84.17 | C84.18 | C84.19 | C84.40 |
C84.41 | C84.42 | C84.43 | C84.44 | C84.45 | C84.46 | C84.47 |
C84.48 | C84.49 | C84.60 | C84.61 | C84.62 | C84.63 | C84.64 |
C84.65 | C84.66 | C84.67 | C84.68 | C84.69 | C84.70 | C84.71 |
C84.72 | C84.73 | C84.74 | C84.75 | C84.76 | C84.77 | C84.78 |
C84.79 | C84.90 | C84.91 | C84.92 | C84.93 | C84.94 | C84.95 |
C84.96 | C84.97 | C84.98 | C84.99 | C84.Z0 | C84.Z1 | C84.Z2 |
C84.Z3 | C84.Z4 | C84.Z5 | C84.Z6 | C84.Z7 | C84.Z8 | C84.Z9 |
C86.2 | C86.5 | C86.6 | C91.50 | C91.52 | Z85.72 |
Professional Statements and Societal Positions Guidelines
NA