CurrentMass General Brigham Health PlanPolicy N/A

Aphexda (motixafortide) — Stem Cell Mobilization (with G‑CSF)

Policy governs prior authorization for Aphexda (motixafortide) used with G-CSF to mobilize hematopoietic stem cells for autologous transplantation in patients with multiple myeloma under the MassHealth plan (medical benefit).

Policy Summary

PayerMass General Brigham Health Plan (MassHealth)

PolicyAphexda (motixafortide) — Stem cell mobilization with G-CSF

Policy CodePolicy N/A

Change TypeClarification and formatting updates

Effective Date07/01/2025

Next Review DateN/A

Key ActionObtain prior authorization and provide documentation including diagnosis of multiple myeloma requiring autologous HCT, oncologist/hematologist prescriber or consult notes, confirmation the agent will be used with G-CSF, clinical rationale if chosen instead of plerixafor, and appropriate dosing.

SourceLink

POLICY UPDATE CHANGES

Clarified consult notes are acceptable to meet the prescriber specialty requirement.

Updated formatting and references.

3 moinitial approval duration

up to 2reauth dosing

MassHealthapplicable plan(s)

Coverage Criteria for Aphexda (motixafortide)

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inv-01: Initial Therapy

Authorization may be granted when ALL of the following are met:

Initial Authorization

Diagnosis of multiple myeloma requiring autologous hematopoietic cell transplantation (HCT)
Prescriber is an oncologist or hematologist or consult notes from an oncologist or hematologist are provided
Clarified consult notes acceptable per review history
Concomitant therapy: Requested agent will be used in combination with a granulocyte colony stimulating factor (G-CSF)
Therapeutic rationale: Clinical rationale provided for use of the requested agent instead of plerixafor
Dosing: Appropriate dosing is documented

Indication (supporting clinical context): Use is to mobilize hematopoietic stem cells for collection and subsequent autologous transplantation in patients with multiple myeloma

inv-02: Continuation of Therapy / Limitations

Continuation of therapy and limitations

Continuation

Single additional dose: Members who have received one dose and require an additional dose can be approved for an additional 3 months
>2 doses: Requests for greater than two total doses require documentation of medical necessity and will be reviewed on a case-by-case basis

Limitations: Initial approvals will be granted for 3 months; reauthorizations follow the Continuation criteria above

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Aphexda (motixafortide) is a medical-benefit drug requiring prior authorization when used for mobilization for autologous hematopoietic cell transplantation (HCT).

Medical-benefit drug
Prior authorization required for mobilization use

Step Therapy

Step / Alternative Agent Consideration

Step/Alternative Agent Consideration — A clinical rationale must be provided when choosing motixafortide (Aphexda) instead of plerixafor. Requests should explain why plerixafor is not appropriate or sufficient for the member.

Clinical rationale required when motixafortide chosen instead of plerixafor

Documentation Required

Required Clinical Documentation

Required Clinical Documentation — Provide documentation of the diagnosis, prescriber specialty or consult notes, treatment plan showing use with a G-CSF, and dosing information. Prescriber must be an oncologist or hematologist, or submit consult notes from one.

Diagnosis: multiple myeloma requiring autologous HCT
Prescriber: oncologist or hematologist, or consult notes from one
Documentation that agent will be used with a G-CSF
Appropriate dosing information

Denial Risk

Missing Documentation Denial Risk

Missing Documentation Denial Risk — Requests that lack required documentation (diagnosis, prescriber specialty/consult notes, clinical rationale for motixafortide versus plerixafor, or dosing) may be denied or returned for additional information.

Requests missing required documentation or prescriber specialty may be denied or returned
Recertification > two total doses requires documentation of medical necessity and will be reviewed case-by-case

Regimen	Indication	Coverage status
Aphexda (motixafortide) + filgrastim (G-CSF)	Mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with multiple myeloma	Covered with criteria

Definitions

inv-09: Stem cell mobilization (with Aphexda + G-CSF) — definition of mobilization for autologous transplantation.

DefinitionMobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous transplantation in patients with multiple myeloma.

Agent combinationAphexda (motixafortide) administered in combination with filgrastim (G-CSF).

Indication contextUse is for pre‑transplant stem cell mobilization prior to autologous hematopoietic cell transplantation (HCT).

Applicable populationPatients with multiple myeloma requiring autologous transplantation.

Policy scopeCoverage pertains to Aphexda under the medical benefit when used with G‑CSF for stem cell mobilization.

Background

Motixafortide (Aphexda), when used in combination with a granulocyte colony‑stimulating factor (G‑CSF; e.g., filgrastim), is indicated to mobilize hematopoietic stem cells to the peripheral blood for collection and subsequent autologous hematopoietic cell transplantation in patients with multiple myeloma. This policy applies to Aphexda administered under the medical benefit for MassHealth members and requires prior authorization per the policy’s coverage criteria.