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Anthem Blue Cross California Adakveo (crizanlizumab Form


Adakveo (crizanlizumab) initial use

Indications

(912998) Is the patient 16 years of age or older? 
(912999) Does the patient have a diagnosis of sickle cell disease? 
(913000) Is there documentation provided that the patient had at least two episodes of sickle cell related pain crises in the past 12 months? 
(913001) Is the patient not using Adakveo (crizanlizumab) in combination with voxelotor (Oxbryta)? 

Adakveo (crizanlizumab) continuation use

Notes: Note: Continuation requests may only be approved if the aforementioned criterion is met.

Indications

(913002) Is there documentation provided that the individual experienced a reduction in acute complications of sickle cell disease (e.g., reduction in the number of vaso-occlusive episodes, acute chest syndrome episodes) since initiation of Adakveo? 

Effective Date

06/20/2023

Last Reviewed

05/19/2023

Original Document

  Reference



Overview

This document addresses the use of Adakveo (crizanlizumab). Crizanlizumab is a monoclonal antibody that binds to and inhibits P-selectin, an adhesion protein found on the surface platelets and endothelial cells. In those with sickle cell disease, P-selectin promotes blood vessels \

HCPCS

J0791

Injection, crizanlizumab-tmca, 5 mg (Adakveo) (Effective 7/1/2020)

ICD-10 Diagnosis

D57.00-D57.819

Sickle Cell Disease

Document History

Revised: 05/19/2023