CurrentAnthemPolicy CC-0117

Empliciti (elotuzumab) — Clinical Prior Authorization and Medical Necessity Criteria

Clinical prior authorization and medical necessity criteria for Empliciti (elotuzumab) for treatment of multiple myeloma, applied to Anthem members.

Policy Summary

PayerAnthem

PolicyEmpliciti (elotuzumab) — Clinical Prior Authorization and Medical Necessity Criteria

Policy CodePolicy CC-0117

Change TypeNo material change

Effective DateDec 22, 2025

Next Review DateN/A

Key ActionSubmit prior authorization; approval requires meeting the clinical criteria including diagnosis, age, and required combination regimen.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

J9176HCPCS code for elotuzumab

1+Lenalidomide combo prior therapy

>=2Pomalidomide combo prior therapies

NCApplicable state

Coverage Criteria for Empliciti (elotuzumab)

Initial Therapy / Authorization Criteria

Policy Summary

PayerAnthem

PolicyEmpliciti (elotuzumab) — Clinical Prior Authorization and Medical Necessity Criteria

Policy CodePolicy CC-0117

Change TypeNo material change

Effective DateDec 22, 2025

Next Review DateN/A

Key ActionSubmit prior authorization; approval requires meeting the clinical criteria including diagnosis, age, and required combination regimen.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Pediatric indication: Individual is under 19 years of age

Pediatric approval pathway (single criterion)

Adult multiple myeloma indication: Individual has a diagnosis of relapsed, progressive, or refractory multiple myeloma, including plasma-cell leukemia; AND disease is relapsed, progressive, or refractory following at least one prior therapy; AND the drug will be used in combination with one of the listed regimens (lenalidomide + dexamethasone OR bortezomib + dexamethasone OR pomalidomide + dexamethasone).

Pomalidomide combination requires at least two prior therapies including lenalidomide and a proteasome inhibitor per document.

Covered Combination Regimens

Regimen	Indication	Coverage
Lenalidomide + dexamethasone
Relapsed, progressive, or refractory multiple myeloma (including plasma-cell leukemia)
Covered with criteria

Regimen	Indication	Coverage
Bortezomib + dexamethasone
Relapsed or progressive multiple myeloma per NCCN (2A)
Covered with criteria

Regimen	Indication	Coverage
Pomalidomide + dexamethasone
Relapsed, progressive, or refractory multiple myeloma in individuals who have received at least two prior therapies including lenalidomide and a proteasome inhibitor
Covered with criteria

Line of Therapy Criteria

second-line

Lenalidomide combination: Used in combination with lenalidomide and dexamethasone for individuals who have received one to three prior therapies per FDA label.

third-line_or_later

Pomalidomide combination: Used in combination with pomalidomide and dexamethasone for individuals who have received at least two prior therapies including lenalidomide and a proteasome inhibitor per FDA label.

other

Bortezomib combination (NCCN): Use in combination with bortezomib and dexamethasone supported by NCCN (category 2A) for previously treated myeloma for relapsed or progressive disease.

Prior therapies required

Lenalidomide combinationAt least 1 prior therapy required (FDA: used with lenalidomide + dexamethasone for individuals who have received one to three prior therapies).

Pomalidomide combinationAt least 2 prior therapies required, including prior lenalidomide and a proteasome inhibitor (FDA-approved indication requires ≥2 prior therapies including lenalidomide and a proteasome inhibitor).

Bortezomib combinationNo specific minimum prior-therapy count in this document; supported by NCCN (category 2A) for previously treated relapsed or progressive disease.

Coding — Diagnosis and Procedure Codes

HCPCSHCPCSCovered

J9176

Injection, elotuzumab, 1 mg [Empliciti]

ICD-10 DiagnosisICD-10

C90.00-C90.32	Multiple myeloma and malignant plasma cell neoplasms
Z85.79	Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues

Prior therapies required (clinician reference)

Lenalidomide combinationAt least 1 prior therapy required (FDA: used with lenalidomide + dexamethasone for individuals who have received one to three prior therapies).

Bortezomib combinationNo specific minimum prior-therapy count in this document; supported by NCCN (category 2A) for previously treated relapsed or progressive disease.

Provider Actions and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests may be approved only if clinical criteria are met, including age, diagnosis, prior therapy, and required combination regimen; requests that do not meet the clinical criteria or are for other indications may be denied.

Prior authorization required for Empliciti (elotuzumab)
Approval contingent on meeting all clinical criteria in the policy (age/diagnosis/prior therapy/combination regimen)
Requests not meeting criteria or for other indications may be denied

Step Therapy

Step Therapy / Combination Regimen Requirements

There is no step-therapy sequence mandated beyond the combination regimen requirements specified in the coverage criteria. However, approval requires that Empliciti be used in combination with an allowed regimen (lenalidomide + dexamethasone; bortezomib + dexamethasone; or pomalidomide + dexamethasone in patients with at least two prior therapies including lenalidomide and a proteasome inhibitor).

No additional step-therapy sequence specified beyond combination regimen requirements
Allowed combination regimens: lenalidomide + dexamethasone; bortezomib + dexamethasone (NCCN 2A); pomalidomide + dexamethasone (requires ≥2 prior therapies including lenalidomide and a proteasome inhibitor)

Documentation Required

Documentation Note — Coding and Coverage Verification

Coding for treatment and procedures is provided for informational purposes only. Inclusion or omission of codes does not guarantee member coverage or provider reimbursement — verify the member contract and benefits in effect at time of service.

Coding listed in the policy is informational only
Confirm member coverage and reimbursement via the member's contract at time of service

Denial Risk

Denial Triggers

Requests for Empliciti may be denied when the policy clinical criteria are not met (including age, diagnosis, prior therapy, and required combination regimen) and for all other non‑approved indications.

Denial triggers include failure to meet age/diagnosis/prior therapy/combination regimen criteria
Denials may occur for any indication not supported by the policy

Definitions

Multiple myeloma — definition

DefinitionA type of cancer that begins in plasma cells (white blood cells that produce antibodies).

Disease contextIncludes relapsed, progressive, or refractory presentations considered for Empliciti in combination regimens per this policy.

Related conditionsMay include progression to plasma-cell leukemia as noted in policy coverage criteria.

Plasma cell leukemia — definition

DefinitionA rare and aggressive form of multiple myeloma characterized by high levels of plasma cells in the peripheral blood.

Policy relevanceExplicitly included among eligible diagnoses for Empliciti when disease is relapsed, progressive, or refractory.

Clinical noteConsidered within the same coverage criteria as relapsed/refractory multiple myeloma for combination regimens listed in this policy.

Progressive disease — definition

DefinitionFor cancer, disease that is growing (e.g., growth in size of tumor), spreading, or worsening.

Policy useProgressive disease is one of the qualifying disease states (relapsed, progressive, or refractory) for Empliciti coverage in this document.

Clinical implicationProgression following prior therapy is required per the listed criteria before Empliciti combinations are authorized.

Proteasome inhibitors — definition and examples

DefinitionA class of drugs that block the action of proteasomes, cellular complexes that break down proteins (examples: bortezomib, carfilzomib, ixazomib).

ExamplesBortezomib, carfilzomib, ixazomib (listed as examples in the document).

Policy relevanceAt least one prior proteasome inhibitor is required when using Empliciti with pomalidomide + dexamethasone per FDA indication.

Background

Empliciti (elotuzumab) is a humanized IgG1 monoclonal antibody that targets SLAMF7 on myeloma and natural killer cells, activating NK-cell–mediated antibody-dependent cellular cytotoxicity. It is used in combination regimens for multiple myeloma; FDA- and guideline-supported combinations in this policy include lenalidomide + dexamethasone, bortezomib + dexamethasone (NCCN 2A), and pomalidomide + dexamethasone (the latter for individuals with at least two prior therapies including lenalidomide and a proteasome inhibitor).