Aphexda (motixafortide) prior authorization for autologous transplantation in multiple myeloma
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This form governs prior authorization and step-edit requests for Aphexda (motixafortide) when used to mobilize stem cells for autologous transplantation in multiple myeloma patients; it affects prescribers, pharmacists, and AvMed members in North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria for Aphexda (motixafortide)
Initial authorization criteria
Covered when ALL of the following are met
Prescriber must provide planned transplant date
Coverage may NOT be renewed.
Requests to initiate therapy using samples do not meet preauthorization criteria; use of samples to initiate therapy does not meet step edit/preauthorization criteria and previous therapies will be verified through pharmacy paid claims or submitted chart notes.
Coding and Billing
| J2277 | motixafortide (Aphexda) (Medical) |
| ICD-10 | ICD code — space provided for applicable diagnosis code |
Provider Actions and Requirements
Prior authorization required for Aphexda (J2277)
Prior authorization is required for Aphexda (motixafortide) (J2277) per this medical prior authorization/step-edit request form; prescriber signature and submitted supporting documentation are required for review.
- Drug Requested: Aphexda (motixafortide) (J2277) (Medical) is subject to prior authorization as indicated on the form.
- Prescribing physician must sign and clearly print name on the request; preprinted stamps are not valid.
Samples not acceptable; prior therapy will be verified
Requests that rely on samples to initiate therapy do not meet step-edit/preauthorization criteria; prior therapies will be verified through pharmacy paid claims or submitted chart notes.
- Use of samples to initiate therapy is explicitly not acceptable to satisfy the step-edit/preauthorization.
- Previous therapies will be checked via pharmacy paid claims or chart notes to confirm prior treatment history.
Required prescriber signature and supporting documentation
The prescriber must sign and clearly print their name on the request (preprinted stamps are not valid) and provide documentation to support each checked clinical criterion including lab results, diagnostics, and chart/progress notes; planned transplant date and verification of filgrastim use must be included.
- Prescribing physician signature and printed name required on the form.
- Provide documentation for each checked criterion: lab results, diagnostics, chart/progress notes, planned transplantation date, and evidence of filgrastim (G-CSF) use (chart notes and/or pharmacy/medical paid claims).
Incomplete or illegible submissions may delay or cause denial
Incomplete, incorrect, or illegible information — including missing documentation, labs, diagnostics, or chart notes — may delay review or result in denial of authorization.
- Ensure all requested fields (including phone and fax numbers) are complete and legible to avoid delays.
- Missing supporting documentation for checked clinical criteria may lead to denial.
Background
Motixafortide (Aphexda) is requested as a stem cell mobilization agent to be used in combination with filgrastim (G-CSF) for autologous transplantation in multiple myeloma patients. Authorization is for one treatment consisting of up to two doses per transplant, with administration of the medication and filgrastim 10 to 14 hours prior to apheresis; a second dose (1.25 mg/kg) may be given 10 to 14 hours prior to a third apheresis. Dosing limits include a maximum of 124 mg (2 vials) per dose and a quantity limit of 2 vials per dose for up to two doses.
Definitions and Administration Details
Line of Therapy / Salvage
salvage
Covered Regimens and Dosing
| Regimen | Administration timing | Dose details | Dosing limits |
|---|---|---|---|
| Aphexda (motixafortide) for stem cell mobilization in autologous transplantation (used with filgrastim [G-CSF]) | |||
| Single dose administered 10 to 14 hours prior to the first apheresis; an optional second dose may be administered 10 to 14 hours prior to a third apheresis | |||
| First dose as single dose; second (optional) dose specified at 1.25 mg/kg (prescriber must submit recent chart/progress notes detailing planned regimen) | |||
| One treatment per transplant consisting of up to two doses; maximum 124 mg (2 vials) per dose; quantity limit 62 mg single‑dose vial — 2 vials per dose for two doses only |
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