Anthem Blue Cross California Aphexda (motixafortide) Form

Overview

This document addresses the use of Aphexda (motixafortide), a chemokine receptor type 4 inhibitor which impairs binding of hematopoietic stem cells within the bone marrow microenvironment. Aphexda is approved in combination with filgrastim to mobilize hematopoietic stem cells to the peripheral blood for subsequent autologous transplantation in individuals with multiple myeloma.

National Comprehensive Cancer Network (NCCN) Guideline Recommendation

The NCCN guideline on Hematopoietic Cell Transplantation recommends the use of Aphexda in combination with filgrastim (or biosimilar) or tbo-filgrastim as a hematopoietic cell mobilization regimen for autologous donors undergoing transplantation for multiple myeloma.

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.

Aphexda (motixafortide)

Requests for Aphexda (motixafortide) may be approved if the following criteria are met:

• I. Individual is 18 years or older; AND
• II. Individual has a diagnosis of multiple myeloma; AND
• III. Aphexda is being used to mobilize autologous hematopoietic stem cells; AND
• IV. After stem cell mobilization and collection, a subsequent autologous hematopoietic stem cell transplant is anticipated; AND
• V. Individual is using in combination with filgrastim, filgrastim biosimilar, or tbo-filgrastim (NCCN 2A); AND
• VI. The total number of Aphexda injections does not exceed two doses total; one dose prior to first and third apheresis.

Requests for Aphexda (motixafortide) may not be approved for the following:

• I. More than one treatment cycle*; OR
• II. When the above criteria are not met or for all other indications.
• III. Individual is using as a mobilizing agent for an allogeneic stem cell donor (NCCN); OR
• IV. Individual is using as a mobilizer of leukemic cells; OR
• Approval duration: *One treatment cycle (includes two doses total; one dose prior to first and third apheresis)

Coding

1. 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.
2. J3490
3. J3590
4. J9999
5. Unclassified drugs (when specified as Aphexda)
6. Unclassified biologics (when specified as Aphexda)
7. Not otherwise classified, antineoplastic drugs (when specified as Aphexda)

ICD-10 Diagnosis

Document History

New: 11/17/2023