Carfilzomib (Kyprolis) (CPB 0845, reviewed 2026-03-02)

By March 2, 2026: (1) Billing team must implement mandatory precertification requirement for all Carfilzomib (J9047) claims for multiple myeloma in billing software and prior authorization system. (2) Update authorization protocols to require submission to (866) 752-7021 or fax (888) 267-3277 BEFORE service delivery. (3) Configure system to validate that requested indication matches one of the covered criteria: transplant candidate with specific combination therapy, prior lines of therapy, relapsed/refractory disease with approved combinations, or maintenance therapy with lenalidomide. (4) Program system to deny claims for experimental/investigational uses including concomitant proteasome inhibitor therapy, primary plasma cell leukemia, and listed non-covered conditions (breast cancer, lung cancer, mantle cell lymphoma, etc.). (5) Establish dosing validation rules: twice-weekly max 56 mg/m² (not to exceed 124 mg per dose, max 6 doses per 28 days) OR once-weekly max 70 mg/m² (not to exceed 154 mg per dose, max 3 doses per 28 days). (6) Training for prior authorization staff and billing team on new criteria before effective date. (7) Provider communication: send notification to all oncology and hematology providers regarding new precertification requirements and covered combinations. Failure to obtain precertification will result in claim denials.