Gamifant (Emapalumab-Lzsg) (for Louisiana Only)
UnitedHealthcare Medical Benefit Drug Policy applicable only to Louisiana members covering use of emapalumab (Gamifant) for primary hemophagocytic lymphohistiocytosis (HLH) with specified clinical criteria, dosing limits, and coding guidance. Includes FDA indication, clinical evidence summary, and applicable HCPCS and ICD-10 codes.
Supporting information updated; References section updated.
Coverage Summary
Coverage stance: covered_with_criteria — emapalumab (Gamifant) is covered when the policy’s specified criteria are met for primary hemophagocytic lymphohistiocytosis (HLH). Scope: This UnitedHealthcare Medical Benefit Drug Policy applies only to Louisiana members. FDA indication summary: Gamifant is indicated for treatment of adult and pediatric patients with primary HLH with refractory, recurrent, or progressive disease or intolerance to conventional HLH therapy. Payer/geographic applicability: UnitedHealthcare — Louisiana only. High-level approval limits: approval duration is limited to no more than 6 months, and dosing must follow the FDA-approved labeling.
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