CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Aphexda (motixafortide) — Hematopoietic Cell Mobilization Coverage Criteria

Defines accepted indications, contraindications, exclusions, coding, and prior authorization expectations for Aphexda (motixafortide) used primarily to mobilize hematopoietic stem cells for autologous transplant in multiple myeloma; applies to Neighborhood Health Plan of Rhode Island members administered via Evolent processing.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAphexda (motixafortide) — Hematopoietic Cell Mobilization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization documenting use for hematopoietic stem cell mobilization in multiple myeloma with supporting evidence per policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1covered primary indication (multiple myeloma stem cell mobilization)

1listed HCPCS code for drug billing (J2277)

1.25 mg/kgsingle-dose maximum excluded if exceeded

Commercial; Exchange; Medicaidlines of business applicable

Coverage Criteria for Aphexda (motixafortide)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial therapy / Covered indication

Covered when ALL of the following are met

Primary indication: Member has multiple myeloma and the request is for mobilization of hematopoietic stem cells for collection and subsequent autologous transplantation.

Supported by policy statement and intended use.

Concomitant therapy: Aphexda (motixafortide) will be used in combination with filgrastim (G-CSF).

Policy specifies combination with G-CSF.

Evidence support: Use is supported by FDA approved labeling, CMS-recognized compendia, NCCN or ASCO guidelines, or acceptable peer-reviewed literature per the policy's evidence standards.

See Purpose and References.

Dosing limit: Requested dosing does not exceed single dose limit of 1.25 mg/kg.≤ 1.25 mg/kg

Exceeding this is an exclusion.

Requests for dosing that exceed the policy's single-dose maximum will be excluded. The policy defines the single dose limit for Aphexda (motixafortide) as ≤ 1.25 mg/kg; any request with dosing above this threshold is not approvable and will be denied.

Requests for investigational use or off-label indications for Aphexda (motixafortide) that lack sufficient evidence or general acceptance will be considered not approvable. The policy requires support from FDA labeling, CMS‑recognized compendia, or acceptable peer‑reviewed literature; evidence that is limited to case reports, abstracts without full peer‑reviewed publication, or otherwise does not adequately represent the patient population, regimen, or clinically meaningful outcomes (per ASCO definitions) will not meet the policy standard.

Regimen	Indication / Use	Required combination	Coverage status
Motixafortide (Aphexda)	Hematopoietic stem cell mobilization for autologous transplant in multiple myeloma	Filgrastim (G-CSF)	Covered
Dose / administration	Single-dose limit ≤ 1.25 mg/kg per policy; dosing must not exceed this limit	Administered in combination with filgrastim per regimen	Covered

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Aphexda (motixafortide). Requests must document the indication for hematopoietic stem cell mobilization and include supporting evidence consistent with FDA labeling, CMS compendia, NCCN/ASCO guidelines, or peer‑reviewed literature.

Aphexda (motixafortide) prior authorization required for hematopoietic stem cell mobilization
Supportive documentation must reference FDA labeling, CMS compendia, NCCN/ASCO or peer‑reviewed literature

Prior Authorization

Required Combination Therapy

Aphexda (motixafortide) must be used in combination with filgrastim (G‑CSF) for hematopoietic stem cell mobilization. Documentation should state the planned or ongoing use of filgrastim with the motixafortide request.

Required combination: filgrastim (G‑CSF) + Aphexda (motixafortide)
Requests lacking documentation of combination therapy may be denied

Documentation Required

Clinical Support and Continuation Documentation

Supportive clinical documentation must reference FDA labeling, CMS‑recognized compendia, NCCN or ASCO guidelines, or acceptable peer‑reviewed literature to establish appropriateness of use. Continuation requests are eligible only if prior conditions for continuation are met and no new agents are added.

Acceptable evidence: FDA labeling, CMS compendia, NCCN/ASCO, or peer‑reviewed literature
Continuation criteria: no disease progression, prior use within last year without >30 day lapse, and no additional medications added

Denial Risk

Dose Limit Exceeded

Requests where dosing exceeds the single dose limit of Aphexda (motixafortide) 1.25 mg/kg will be excluded/denied.

Single dose limit: Aphexda (motixafortide) 1.25 mg/kg

Denial Risk

Insufficient Evidence for Off‑Label Use

Use of Aphexda (motixafortide) for investigational or off‑label indications without sufficient supporting evidence (per CMS compendia, NCCN/ASCO, or acceptable peer‑reviewed literature) will be denied.

Off‑label or investigational uses require strong supporting evidence; case reports and abstracts without full peer‑reviewed articles are generally insufficient
Evidence considerations include patient/cancer representation, regimen representation, clinically meaningful outcomes, and appropriate study design

Definitions

Hematopoietic cell mobilization — Aphexda (motixafortide)

DefinitionUse of Aphexda (motixafortide) in combination with filgrastim (G-CSF) to mobilize hematopoietic stem cells to peripheral blood for collection and subsequent autologous transplantation in members with multiple myeloma.

Required concomitant agentFilgrastim (G-CSF) — Aphexda is specified for use in combination with filgrastim for mobilization

Intended purposeMobilization of hematopoietic stem cells for collection prior to autologous transplant

Covered populationMembers with multiple myeloma undergoing autologous transplantation

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAphexda (motixafortide) — Hematopoietic Cell Mobilization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization documenting use for hematopoietic stem cell mobilization in multiple myeloma with supporting evidence per policy.

SourceLink

On This Page

OpenPayer

Aphexda (motixafortide) — Hematopoietic Cell Mobilization Coverage Criteria

Coverage Criteria for Aphexda (motixafortide)

Covered Regimens

Coding and Dose Limits

Provider Actions and Prior Authorization

Definitions

Background

Line of Therapy / Informational