In September, the Food and Drug Administration approved the drug Lumoxiti for the treatment of adult patients with relapsed or refractory hairy cell leukemia. Effective immediately, Harvard Pilgrim will provide coverage for commercial members for Lumoxiti (moxetumomab pasudotox-tdfk) with prior authorization from CVS Health—NovoLogix, when all of the following criteria are met:
- The patient has received at least two prior systemic therapies, including treatment with a purine nucleoside analog.
- The patient has not previously received 6 or more cycles of treatment with Lumoxiti.
Please use the unlisted code J3590 (unclassified biologics) when billing for the use of Lumoxiti. (For information on billing unlisted codes, please refer to the Injectable and Implantable Drugs Payment Policy.) To request authorization, please contact CVS Health–NovoLogix via phone (844-387-1435) or fax (844-851-0882).
For complete information, please refer to Harvard Pilgrim’s new Lumoxiti Prior Authorization Policy and the associated prior authorization request form, which you can you can find on the Medical Drug Prior Authorization page in the Provider section of Harvard Pilgrim’s website.