CommercialPrior AuthMedium impact
Motixafortide (Aphexda) (CPB 1046, reviewed 2025-12-11)
Aetna·Oncology, Hematology·Medical Policy
Effective date
Dec 11, 2025
We identified it
Aug 16, 2026
Summary
Aetna has established a new medical policy (CPB 1046) covering motixafortide (Aphexda) for hematopoietic stem cell mobilization in multiple myeloma patients. The policy requires prior authorization and specifies strict usage criteria: medication must follow 4 days of G-CSF, limited to maximum 2 doses, and used only for stem cell collection prior to apheresis. Billing teams must implement prior authorization requirements and ensure claims include proper ICD-10 codes and supporting documentation.
Action Required
By January 15, 2026: Billing team must implement prior authorization requirement in billing system for HCPCS code J2277 (motixafortide injection). Prior auth must verify: (1) patient diagnosis is multiple myeloma (ICD-10 C90.00-C90.02), (2) patient has received 4 days of G-CSF therapy, (3) medication is for hematopoietic stem cell mobilization, and (4) authorization is limited to maximum 2 doses per transplant cycle. Update claim submission process to require documentation of G-CSF pretreatment and apheresis schedule. Train billing and clinical staff on coverage criteria. Flag any claims for motixafortide exceeding 2 doses or used for non-multiple myeloma indications as non-covered (experimental/investigational). Update encounter templates to capture required clinical documentation. Failure to obtain prior authorization will result in claim denials.