CurrentCommunity-CarePolicy N/A

Adakveo (crizanlizumab) medical benefit

Defines medical benefit coverage, initial and continuation criteria, quantity limits, authorization periods, and applicable billing code for crizanlizumab (Adakveo) for treatment of sickle cell disease in members aged 16 and older.

Policy Summary

PayerCommunity-Care

PolicyAdakveo (crizanlizumab) medical benefit

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must document diagnosis of sickle cell disease, patient age (≥16), prescriber specialty (hematologist) and, if applicable, name of Sickle Cell Center of Excellence or evidence of required trials and evaluations when prescriber is not at a Center of Excellence.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

1Covered Indication (sickle cell disease)

≥16Minimum age (years)

J0791Primary billing code

Coverage Summary

Medical benefit coverage for crizanlizumab (Adakveo) to prevent vaso-occlusive crises in patients with sickle cell disease aged ≥16; coverage stance: covered_with_criteria. Specialist-prescribing expectations and prior therapy requirements (or provision of a named Sickle Cell Center of Excellence when that path is used) are defined in the criteria and required for authorization.

Continuation of Therapy Criteria

Continuation of Therapy

Covered when ALL of the following are met:

ALL of the following

Prescribed by a hematologist
Diagnosis of sickle cell disease
Experienced a decrease in frequency of vaso-occlusive crises from baseline

Authorizations follow the policy's stated periods: initial coverage 6 months and continuation coverage 1 year. Typical dosing cadence referenced for authorization is an initial two doses of 5 mg/kg followed by up to one dose of 5 mg/kg every 28 days (dosage details and full dosing rules are in Provider Actions).

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required with hematologist attestation

Document diagnosis of sickle cell disease, patient age (≥16), and prescriber specialty (hematologist). If the prescriber is affiliated with a Sickle Cell Center of Excellence, provide the center name. If the prescriber is not at a Center of Excellence, provide evidence of the required trials and evaluations (≥3 vaso-occlusive crises in prior 12 months including 1 within 6 months while on hydroxyurea if applicable; trial of hydroxyurea >6 months at maximally tolerated dose if ineffective/intolerant/contraindicated; trial of l‑glutamine if ineffective/intolerant/contraindicated; and comprehensive evaluation/addressing of other pain causes/exacerbators).

J0791

Documentation Required

Weight required for approval

Patient weight must be provided to authorize dosing (5 mg/kg) and to determine quantity limits.

Billing Rule

Dosing and quantity limits

Initial authorization allows an initial fill of two doses of 5 mg/kg followed by up to one dose of 5 mg/kg per 28 days. Initial coverage is authorized for six months; continuation coverage is authorized for one year.

J0791

Background

Crizanlizumab (Adakveo) is indicated for prevention of vaso-occlusive crises in patients with sickle cell disease. The policy defines specialist-prescribing expectations, including that a hematologist prescriber must be involved; when the prescribing path uses a Sickle Cell Center of Excellence, the name of the Center must be provided.

Definition — Sickle Cell Center of Excellence: A named center where a hematologist prescriber is affiliated; name must be provided when used as the prescribing path.

Policy Summary

PayerCommunity-Care

PolicyAdakveo (crizanlizumab) medical benefit

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Adakveo (crizanlizumab) medical benefit

Coverage Summary

Initial Therapy Criteria

Continuation of Therapy Criteria

Exclusions / Combination Use

Applicable Codes

Provider Actions & Prior Authorization

Background

Revision History