CurrentCareSourcePolicy N/A

Aphexda (motixafortide) — Hematopoietic Stem Cell Mobilization Coverage Criteria

Policy governing prior authorization, coverage criteria, dosing, and exclusions for Aphexda (motixafortide) used with filgrastim to mobilize hematopoietic stem cells for collection and subsequent autologous transplantation in patients with multiple myeloma.

Policy Summary

PayerCareSource

PolicyAphexda (motixafortide) — Hematopoietic Stem Cell Mobilization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateOct 2, 2024

Key ActionObtain prior authorization and document age ≥18, diagnosis of multiple myeloma, intent for mobilization for autologous transplantation, prescribing clinician specialty, concomitant filgrastim use, and planned dosing consistent with policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 2doses at 1.25 mg/kg

10–14 htiming before apheresis

multiple myelomaindicated disease

not recommendeduse in leukemia

Coverage Criteria for Aphexda (motixafortide)

Policy Summary

PayerCareSource

PolicyAphexda (motixafortide) — Hematopoietic Stem Cell Mobilization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateOct 2, 2024

SourceLink

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Dosing Criteria

Dosing limits

Dosing: Approve up to two doses at 1.25 mg/kg given by subcutaneous injection; doses administered 10 to 14 hours prior to initiation of apheresis; a second dose can be administered 10 to 14 hours before a third apheresis per policy note.1.25 mg/kg, up to 2 doses

Requests for doses outside this established dosing will be considered case-by-case by clinician.

Regimen	Indication	Required Concomitant Agent	Dosing / Timing	Coverage Status
Aphexda (motixafortide) plus filgrastim (G-CSF)	Mobilization of hematopoietic stem cells for subsequent autologous transplantation in patients with multiple myeloma	Filgrastim (examples: Granix, Neupogen, or biosimilars)	Approve up to two doses of motixafortide at 1.25 mg/kg given by subcutaneous injection; doses administered 10–14 hours prior to initiation of apheresis (a second dose may be given 10–14 hours before a third apheresis)	Covered with criteria

Provider Requirements and Prior Authorization

Prior Authorization

Prior authorization recommended

Prior authorization is recommended for medical benefit coverage; approvals are granted when the patient meets the Criteria and Dosing described in this policy.

Step Therapy

Combination with filgrastim required

Use of Aphexda must be in combination with filgrastim (G-CSF); the policy and NCCN guidance list Aphexda as an alternative only when given with G-CSF (filgrastim).

Documentation Required

Required documentation for prior auth

Document the patient is ≥18 years old, has a diagnosis of multiple myeloma, and that Aphexda is intended for mobilization of hematopoietic stem cells for subsequent autologous transplantation; include the prescribing clinician specialty and planned concomitant filgrastim use and dosing consistent with policy.

Age ≥ 18 years
Diagnosis: multiple myeloma
Intent: mobilization for subsequent autologous transplantation
Prescribing clinician: hematologist or stem cell transplant specialist
Concomitant filgrastim use and planned dosing per policy (up to two doses at 1.25 mg/kg, SC, 10–14 hours before apheresis)

Denial Risk

Leukemia exclusion

Requests for Aphexda for hematopoietic stem cell mobilization in patients with leukemia are not recommended and may be denied due to the risk of mobilizing leukemia cells and contaminating the apheresis product.

Denial Risk

Failure to meet authorization criteria

Lack of prior authorization or failure to meet the policy's specified criteria (age ≥18, diagnosis of multiple myeloma, use for mobilization for autologous transplantation, prescribed by a hematologist/stem cell transplant specialist, used with filgrastim, and dosing within policy) may result in denial.

Covered Treatment Regimens

Clinical Use	Patient Eligibility Requirements	Prescribing Provider	Prior Authorization / Documentation	Coverage Status
Mobilization of peripheral blood hematopoietic stem cells for collection and subsequent autologous transplantation	Patient is ≥18 years of age; diagnosis of multiple myeloma; intended use is mobilization for subsequent autologous transplantation; used in combination with filgrastim	Hematologist and/or stem cell transplant specialist physician	Prior authorization recommended; documentation should demonstrate age ≥18, diagnosis of multiple myeloma, intent for mobilization for autologous transplant, concomitant filgrastim use, and planned dosing consistent with policy (up to two doses at 1.25 mg/kg given SC 10–14 hours before apheresis)	Covered with criteria

Definitions

inv-12: Stem cell mobilizer — definition of hematopoietic stem cell mobilizer

TermHematopoietic stem cell mobilizer

DefinitionAn agent used to move hematopoietic stem and progenitor cells from the bone marrow into the peripheral blood for collection via apheresis.

Indication ContextUsed in combination with filgrastim (G-CSF) to mobilize hematopoietic stem cells for collection and subsequent autologous transplantation in patients with multiple myeloma.

Clinical PurposeFacilitates collection of sufficient hematopoietic stem and progenitor cells from peripheral blood to support autologous stem cell transplantation (ASCT).

Example AgentAphexda (motixafortide) — indicated in combination with filgrastim for mobilization prior to ASCT in multiple myeloma.

OpenPayer

Aphexda (motixafortide) — Hematopoietic Stem Cell Mobilization Coverage Criteria

Coverage Criteria for Aphexda (motixafortide)

Provider Requirements and Prior Authorization

Covered Treatment Regimens

Definitions

Background