Siltuximab (Sylvant®) is an interleukin-6 (IL-6) antagonist indicated for the treatment of individuals with multicentric Castleman’s disease (MCD) who are human immunodeficiency virus (HIV) negative and human herpesvirus-8 (HHV-8) negative.
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) Indication
Siltuximab (Sylvant) may be considered medically necessary for the treatment of individuals 18 years of age and older with Multicentric Castleman disease (MCD) when ALL of the following criteria are met:
National Comprehensive Cancer Network (NCCN) Indication:
Siltuximab (Sylvant) may be considered medically necessary for the following:
Siltuximab (Sylvant) is considered experimental/investigational for any other indication and therefore non-covered. Scientific evidence does not support its use 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
Professional Statements and Societal Positions Guidelines