Anthem Blue Cross California Sylvant (siltuximab) Form

Overview

This document addresses the use of Sylvant (siltuximab). Sylvant is a monoclonal antibody which binds to interleukin-6 (IL-6) receptors and inhibits release of proinflammatory cytokines primarily used to treat multicentric Castleman’s disease.

Clinical Criteria

When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization), the following criteria will be used to determine whether the drug meets any applicable medical necessity requirements for the intended/prescribed purpose.

Sylvant (siltuximab)

• Requests for Sylvant (siltuximab) may be approved for the following:
1. Individual has a diagnosis of Multicentric Castleman’s; AND
2. Sylvant (siltuximab) is used as a single agent; AND
3. Individual is human immunodeficiency virus negative; AND
4. Individual is human herpesvirus-8 negative; AND
5. No concurrent clinically significant infection (for example, Hepatitis B or C); AND
6. No concurrent lymphoma.
• Requests for Sylvant (siltuximab) may not be approved if the above criteria are not met and for all other indications.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

1. HCPCS J2860 - Injection, siltuximab, 10 mg [Sylvant]

• ICD-10 Diagnosis D47.Z2 - Castleman disease

Document History

Reviewed: 02/25/2022