Ziv-aflibercept (Zaltrap), formerly known as aflibercept, VEGF Trap, is a recombinant fusion protein, which acts as a soluble receptor that binds to vascular endothelial growth factor-A (VEGF-A), VEGF-B and placental growth factor (PIGF). Ziv-aflibercept (Ziltrap) is designed to act as a VEGF trap to prevent activation of VEGF receptors and thus inhibit angiogenesis. Inhibition of these factors can result in decreased neo-vascularization and decreased vascular permeability.
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.
Ziv-aflibercept (Ziltrap) may be considered medically necessary for the treatment of ANY of the following conditions:
Food and Drug Administration (FDA) Indication
National Comprehensive Cancer Network (NCCN) Indications
Colon or Rectal Cancer Adenocarcinoma
Ziv-aflibercept (Ziltrap) is considered experimental/investigational for all other indications 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 for Procedure Code J9400: