Aphexda (motixafortide) coverage for stem cell mobilization
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Defines medical necessity and prior authorization requirements for Aphexda (motixafortide) when used with filgrastim to mobilize hematopoietic stem cells for autologous transplantation across Geisinger Health Plan lines of business.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy (Commercial/Exchange/CHIP/Medicaid)
Aphexda will be considered medically necessary when ALL of the following are met:
Requires prior authorization by Medical Director or designee
Initial Therapy (Medicare)
For Medicare, Aphexda will be considered medically necessary when ALL of the following are met:
Authorization duration: one (1) month
Eligibility and contract specific benefit limitations and/or exclusions will apply. Coverage statements found in the line of business specific benefit document will supersede this policy.
No explicit exclusions are stated in the policy text provided in these sections.
No explicit statements that use of Aphexda (motixafortide) is "not medically necessary" appear in the cited policy excerpts.
Initial Therapy
Initial Therapy
Initial therapy criteria mirror clinical coverage criteria
Prior authorization required
Authorization Duration / Continuation
Authorization Duration / Continuation
Medicaid note: requests not meeting PARP will be evaluated case-by-case
Provider Actions & Requirements
Prior authorization required (Medical Director or designee)
Prior authorization is required for Aphexda and must be obtained from the Medical Director or designee for commercial, exchange, CHIP, and Medicaid lines of business. Coverage is contingent on meeting all listed clinical criteria.
- PA required by Medical Director or designee
- Aphexda covered only when all criteria in policy are met
Medicare prior authorization documentation note
For Medicare members, prior authorization decisions require documentation that the patient is age ≥18, that Aphexda is prescribed by a hematologist or oncologist, and that it will be used in combination with filgrastim for mobilization and collection of hematopoietic stem cells.
- Document patient age ≥18
- Document prescribing provider is a hematologist or oncologist
- Document planned use in combination with filgrastim for mobilization/collection
PA oversight and UM governance documented
Utilization management oversight is noted by MA UM Committee approvals on 5/22/24 and 4/29/25; these entries indicate PA governance though specific additional PA procedures are not detailed within these chunks.
- MA UM Committee approval dates: 5/22/24, 4/29/25
Step therapy: plerixafor failure/intolerance/contraindication required
Prior authorization requires evidence of prior therapeutic failure, intolerance, or contraindication to plerixafor for commercial, exchange, CHIP, and Medicaid before Aphexda is considered medically necessary.
- Must document therapeutic failure, intolerance, or contraindication to plerixafor
No other step therapy requirements specified
No additional step therapy requirements or steps are specified in the referenced chunks.
Required medical record documentation
Medical record documentation must include patient age ≥18, the prescribing provider specialty (hematologist or oncologist), planned use in combination with filgrastim for mobilization and collection of hematopoietic stem cells for autologous transplant, and — for commercial/CHIP/Medicaid — documentation of therapeutic failure, intolerance, or contraindication to plerixafor.
- Patient age ≥18 documented
- Prescribing provider is hematologist or oncologist
- Planned use with filgrastim documented
- For commercial/CHIP/Medicaid: prior failure/intolerance/contraindication to plerixafor documented
Document header / policy title shown
Document header shows the policy title (Aphexda [motixafortide]); no additional or alternate documentation requirements are specified in the referenced chunks.
Denial triggers: missing required documentation
Lack of documentation that Aphexda is prescribed by a hematologist or oncologist, or that it will be used in combination with filgrastim for mobilization and collection of hematopoietic stem cells, or absence of documentation of therapeutic failure/intolerance/contraindication to plerixafor may trigger denial.
- Missing provider specialty (hematologist/oncologist)
- Missing plan to use with filgrastim
- Missing documentation of plerixafor failure/intolerance/contraindication (where required)
No other provider actions specified
No additional provider actions are stated in the referenced chunks beyond the prior authorization, documentation, and step therapy items already described.
Step Therapy Requirements
| Step | Requirement | Line(s) of Business |
|---|---|---|
| 1 | Document therapeutic failure, intolerance, or contraindication to plerixafor | Commercial, Exchange, CHIP, Medicaid |
| Step | Note | Supporting Governance |
|---|---|---|
| 1 | No additional step therapy steps specified in the policy text | MA UM Committee approval dates: 5/22/24; 4/29/25 |
Site of Care
Site-of-care: infusion center — no restrictions specified
No site-of-care restrictions are specified for infusion center use in the provided chunks.
Background
Motixafortide (Aphexda) is a selective CXCR4 antagonist that binds CXCR4 with high affinity and prolonged receptor occupancy, inhibiting CXCR4 interaction with SDF1α/CXCL12 and mobilizing hematopoietic stem and progenitor cells from the bone marrow into peripheral blood when used in combination with filgrastim; mobilized CD34+ cells have engraftment capacity and are used to facilitate collection for subsequent autologous stem cell transplantation.
Definitions
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