CurrentEmblemHealthPolicy MG.MM.PH.403

Aphexda (motixafortide) subcutaneous injection

Covers medical necessity and authorization criteria for Aphexda (motixafortide) used with filgrastim to mobilize hematopoietic stem cells for collection and subsequent autologous transplantation in patients with multiple myeloma.

Policy Summary

PayerEmblemHealth

PolicyAphexda (motixafortide) subcutaneous injection

Policy CodePolicy MG.MM.PH.403

Change TypeAddition to initial criteria — prohibition on concomitant CXCR4 antagonists

Effective DateN/A

Next Review DateFeb 18, 2025

Key ActionSubmit clinical documentation demonstrating the member meets the policy criteria for preauthorization; prior authorization is required and coverage is limited to two doses.

SourceLink

POLICY UPDATE CHANGES

Addition to initial criteria: Patient will not be treated in combination with other CXCR4-antagonists.

2max doses authorized

124 mgmax mg per dose

J2277HCPCS

82737-0073-01NDC

Coverage Criteria for Aphexda (motixafortide)

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Initial

Covered when ALL of the following are met:

Age: Patient is >= 18 years of ageage >= 18

No concurrent CXCR4 antagonist: Patient will not be treated in combination with other CXCR4-antagonists (e.g., mavorixafor, plerixafor)

Added to initial criteria

Indication: Agent is used for mobilization of hematopoietic stem cells for subsequent autologous transplantation in patients with multiple myeloma

Combination with filgrastim: Use is in combination with filgrastim (examples include Granix, Neupogen, or biosimilars); filgrastim dosing and timing per administration guidance

Filgrastim dosing specified in administration section

Prescriber specialty: Medication is prescribed by a hematologist and/or a stem cell transplant specialist physician

Dose limits: Coverage provided for up to two doses only; each authorized dose consists of 2 vials (62 mg per vial) = 124 mg per dosemax 2 doses; 124 mg per dose

Renewal

Renewal: Coverage cannot be renewed (requests for additional doses beyond the two-dose limit are not authorized)

No continuation coverage

Use of Aphexda in combination with other CXCR4-antagonists is not permitted. Examples of prohibited concurrent agents include mavorixafor and plerixafor.

Coverage is limited to a maximum of two doses. Requests for additional doses beyond this two-dose limit are not authorized and coverage cannot be renewed for further administrations.

Regimen component	Details
Repeat dosing (conditional)
If collection goals are not met, a second Aphexda dose may be given 10–14 hours before a subsequent apheresis; overall limit = 2 doses

Billing and Coding

Applicable HCPCS CodesHCPCS

J2277

Injection, Motixafortide, 0.2 mg

Applicable NDCsNDC

82737-0073-01

Aphexda 62 mg One single-dose vial

ICD-10 Diagnoses (as listed)ICD-10

252.011	Autologous donor, stem cells
252.091	Other blood donor, stem cells
294.84	Stem cells transplant status

Maximum dose per administration124 mg per dose (2 vials; each vial 62 mg)

Vials per dose2 vials per dose

Mg per vial62 mg per single-dose vial

Maximum doses authorizedUp to two doses total

Provider Actions and Documentation

Prior Authorization

Prior authorization required; two-dose limit and specialist prescriber

Prior authorization is required for Aphexda; coverage is limited to two doses and the medication must be prescribed by a hematologist and/or a stem cell transplant specialist physician.

Coverage will be provided for two doses only.
Medication is prescribed by a hematologist and/or a stem cell transplant specialist physician.

Step Therapy

Step therapy not applicable

Step therapy is not applicable for this policy; the policy defines initial coverage criteria rather than a required medication sequence.

Documentation Required

Submit clinical documentation for preauthorization

Clinical documentation demonstrating that the member meets the policy criteria and benefit coverage must be submitted for preauthorization or post-payment review.

Denial Risk

Insufficient documentation may lead to denial

Requests lacking documentation that the member meets the clinical criteria will not be able to be properly reviewed and may be denied.

Definitions

Drug name (generic)Motixafortide

Brand nameAphexda

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

Administration contextUsed specifically for peripheral blood stem cell mobilization prior to autologous transplant

Background

Aphexda (motixafortide) is indicated, when used in combination with filgrastim, to mobilize hematopoietic stem cells into the peripheral blood for collection prior to autologous transplantation in patients with multiple myeloma. The regimen specifies Aphexda dosing as a subcutaneous injection given 10–14 hours before apheresis together with filgrastim (examples include Granix and Neupogen) administered per the schedule in the dosing section. Treatment must be prescribed by a hematologist or stem cell transplant specialist and is subject to a maximum of 2 doses, with each dose consisting of up to 124 mg (2 vials).