MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 07/05/18 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
|
|
- Cameron Fisher
- 5 years ago
- Views:
Transcription
1 CINQAIR (reslizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Medical Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as Description defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as Criteria defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Medical Coverage Guidelines are subject to change as new information becomes available. For purposes of this Medical Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other trademarks and service marks contained in this guideline are the property of their respective owners, which are not affiliated with BCBSAZ. O990.3.docx Page 1 of 9
2 CINQAIR (reslizumab) Description: Cinqair (reslizumab) is an interleukin-5 antagonist monoclonal antibody (IgG4 kappa) indicated for add-on maintenance in the treatment of severe asthma with an eosinophilic phenotype. It is administered by a healthcare provider. Definitions: Recurrent Exacerbations: 2 or more acute exacerbations in a 12-month period Severe Asthma: Asthma that does not respond to repeated courses of treatment with beta2-agonist medications. Adult: Age 18 years and older Criteria: See Resources section for FDA-approved dosage and 2016 GINA Guidelines on Stepwise Approach to Treatment of Asthma, Classification of Asthma Control, Asthma Control Test, and Bronchodilators. Cinqair is considered medically necessary for add-on maintenance treatment of individuals aged 18 years and older, with severe asthma with an eosinophilic phenotype with documentation of ALL of the following: 1. Provider is an allergist, immunologist or pulmonologist 2. Individual has been compliant with maximally-dosed inhaled corticosteroid and long acting inhaled beta-2 agonist and another asthma controlling medication (such as LTRA, LAMA, or theophylline) with or without daily oral corticosteroid for at least the last three months 3. Individual has poor control of severe asthma or has recurrent exacerbations requiring additional medication treatment with documentation of ANY of the following: Frequent (two or more) severe asthma exacerbations requiring courses of systemic corticosteroids (steroid burst) within the past 12 months One or more serious asthma exacerbations requiring visit to emergency room or urgent care, or requiring hospitalization or mechanical ventilation within the past 12 months Controlled asthma that worsens when the dose of inhaled or systemic corticosteroid is tapered Baseline forced expiratory volume (FEV1) is less than 80% predicted or has FEV1/FVC < Blood eosinophil count is > 400 cells/microliter within the last 3-4 weeks of dosing O990.3.docx Page 2 of 9
3 Criteria: (cont.) Cinqair is considered medically necessary for add-on maintenance treatment of individuals with severe asthma 18 years of age and older, and with an eosinophilic phenotype with documentation of ALL of the following: (cont.) 5. Individual s underlying conditions or triggers for asthma or pulmonary disease are being maximally managed 6. Will not be used for the relief of acute bronchospasm or status asthmaticus 7. Will not be used for the treatment of other eosinophilic conditions 8. Will not be used concurrently with Fasenra (benralizumab), Nucala (mepolizumab), Xolair (omalizumab), or Dupixent (dupilumab) 9. Absence of ALL of the following contraindications: Hypersensitivity to reslizumab or any of its excipients Continuation of Cinqair is considered medically necessary with documentation of ALL of the following: 1. ONE of the following: Decrease dose of inhaled corticosteroids (ICS) Decrease need for systemic corticosteroids Decreased utilization of rescue medications Increase in predicted FEV1 from baseline Decrease in hospitalizations/emergency room visits Decreased exacerbations 2. Must be using and is adherent with ICS-containing asthma controller medication(s) 3. NOT used for the treatment of other eosinophilic conditions 4. NOT used for the relief of acute bronchospasm or status asthmaticus 5. NOT used with Fasenra (benralizumab), Nucala (mepolizumab), Xolair (omalizumab), or Dupixent (dupilumab) O990.3.docx Page 3 of 9
4 Criteria: (cont.) Cinqair for all other indications not previously listed or if above criteria not met is considered experimental or investigational based upon: 1. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and 2. Insufficient evidence to support improvement of the net health outcome, and 3. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives. These indications include, but are not limited to: Acute bronchospasm Other eosinophilic conditions Status asthmaticus Treatment with dosing or frequency outside the FDA-approved dosing and frequency Resources: Literature reviewed 07/05/18. We do not include marketing materials, poster boards and nonpublished literature in our review. 1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Accessed 01/24/2018. Available at 2. UpToDate. An overview of asthma management. 10/05/2017. Cinqair Package Insert. 03/23/2016: - FDA-approved indication and dosage: Indication As add-on maintenance treatment in individuals with severe asthma 18 years and older and with an eosinophilic phenotype Recommended Dose 3 mg/kg intravenous every 4 weeks. Initial Approval Duration: 3 months Renewal Approval Duration: 12 months O990.3.docx Page 4 of 9
5 Resources: (cont.) 2016 GINA Guidelines on Stepwise Approach to Treatment of Asthma Coding: HCPCS: C9399, C9481, J2786, J3490, J3590 Coding Updates: 12/19/16 Added: HCPCS code J /05/16 Added: HCPCS code C9481 O990.3.docx Page 5 of 9
6 Resources: (cont.) Classification of Asthma Control (12 years of age and older) Well Controlled Not Well Controlled Very Poorly Controlled Symptoms < 2 days/week > 2 days/week Throughout the day Nighttime awakenings < 2 days/month 1-3x/week > 4x/week Interference with normal activities None Some limitation Extremely limited SABA use to control symptoms (not for EIB prevention < 2 days/week > 2 days/week Several times/day FEV1 or peak flow > 80% predicted or personal best 60-80% predicted or personal best Asthma Control Test > < 15 < 60% predicted or personal best Asthma Control Test 1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? All of the time [1] Most of the time [2] Some of the time [3] A little of the time [4] None of the time [5] 2. During the past 4 weeks, how often have you had shortness of breath? More than once a day [1] Once a day [2] 3 to 6 times a week [3] Once or twice a week [4] Not at all [5] 3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? 4 or more nights a week [1] 2 to 3 nights a week [2] Once a week [3] Once or twice [4] Not at all [5] 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 3 or more times per day [1] 1 to 2 times per day [2] 2 or 3 times per week [3] Once a week or less [4] Not at all [5] 5. How would you rate your asthma control during the past 4 weeks? Not Controlled at all [1] Poorly controlled [2] Somewhat controlled [3] Well controlled [4] Completely controlled [5] Score: O990.3.docx Page 6 of 9
7 Resources: (cont.) Bronchodilators Short-acting beta-agonists (SABA) Long-acting beta-agonists (LABA) Short-acting antimuscarinics (SAMA) Long-acting antimuscarinics (LAMA) Inhaled corticosteroids (ICS) Combination products Antimuscarinics/beta agonist ICS/LABA Other Leukotriene Receptor Antagonists (LRTA) Xanthine derivatives albuterol (ProAir HFA, ProAir RespiClick, Proventil HFA, Ventolin HFA) levalbuterol (Xopnenx HFA) formoterol (Foradil aerolizer) indacaterol (Arcapta Neohaler) olodaterol (Striverdi Respimat) salmeterol (Serevent Diskus) ipratropium (Atrovent HFA) aclidinium (Tudorza Pressair) glycopyrrolate (Seebri Neohaler) tiotropium (Spiriva, HandiHaler, Spiriva Respimat) umeclidinium (Incruse Ellipta) beclomethasone (Qvar) budesonide (Pulmicort Flexhaler) ciclesonide (Alvesco) flunisolide (Aerospan) fluticasone (Arnuity Ellipta, Flovent Diskus, Flovent HFA) mometasone (Asmanex, Asmanex HFA) ipratropium/albuterol (Combivent Respimat) glycopyrrolate/formoterol (Bevespi Aerosphere) glycopyrrolate/indacaterol (Utibron) tiotropium/olodaterol (Stiolto Respimat) umeclidinium/vilanterol (Anoro Ellipta) budesonide/formoterol (Symbicort) fluticasone/salmeterol (Advair HFA, Advair Diskus) fluticasone/vilanterol (Breo Ellipta) mometasone/formoterol (Dulera) montelukast (Singulair) zafirlukast (Accolate) zileuton (Zyflo, Zyflo CR) theophylline O990.3.docx Page 7 of 9
8 CINQAIR (reslizumab) Non-Discrimination Statement: Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call (602) for Spanish and (877) for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ , (602) , TTY/TDD (602) , crc@azblue.com. You can file a grievance in person or by mail or . If you need help filing a grievance BCBSAZ s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Multi-Language Interpreter Services: O990.3.docx Page 8 of 9
9 CINQAIR (reslizumab) Multi-Language Interpreter Services: (cont.) O990.3.docx Page 9 of 9
FASENRA (benralizumab)
FASENRA (benralizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationTRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder
TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
NUCALA (mepolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationALPHA1-PROTEINASE INHIBITORS
ALPHA1-PROTEINASE INHIBITORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationAIRDUO RESPICLICK (fluticasone-salmeterol) aerosol DULERA (mometasone furoate and formoterol fumarate dihydrate) aerosol
DULERA (mometasone furoate and formoterol fumarate dihydrate) aerosol Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific
More informationreslizumab (Cinqair )
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
More informationSelect Inhaled Respiratory Agents
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
More informationLARTRUVO (olaratumab)
LARTRUVO (olaratumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationSTELARA (ustekinumab)
STELARA (ustekinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationSTRIVERDI RESPIMAT (olodaterol hcl) aerosol
STRIVERDI RESPIMAT (olodaterol hcl) aerosol Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy
More informationPANCREATIC ISLET TRANSPLANT
PANCREATIC ISLET TRANSPLANT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationENDOBRONCHIAL ULTRASOUND FOR DIAGNOSIS AND STAGING OF LUNG CANCER
CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 10/04/17 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
BAVENCIO (avelumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationENTYVIO (vedolizumab)
ENTYVIO (vedolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationIMMUNE CELL FUNCTION ASSAY
IMMUNE CELL FUNCTION ASSAY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationGENETIC TESTING FOR PREDICTING RISK OF NONFAMILIAL BREAST CANCER
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationGENETIC TESTING FOR TAMOXIFEN TREATMENT
GENETIC TESTING FOR TAMOXIFEN TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationbenralizumab (Fasenra )
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
More informationAPOKYN (apomorphine hydrochloride)
APOKYN (apomorphine hydrochloride) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationCIMZIA (certolizumab pegol)
CIMZIA (certolizumab pegol) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationGENETIC TESTING FOR KRAS, NRAS AND BRAF VARIANT ANALYSIS IN METASTATIC COLORECTAL CANCER
METASTATIC COLORECTAL CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationMOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES
MOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
XOLAIR (omalizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationMYLOTARG (gemtuzumab ozogamicin)
MYLOTARG (gemtuzumab ozogamicin) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR EPITHELIAL OVARIAN CARCINOMA
CARCINOMA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationRADIOFREQUENCY ABLATION OF PRIMARY OR METASTATIC LIVER TUMORS
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationBLINCYTO (blinatumomab)
BLINCYTO (blinatumomab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationRELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE
RELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for
More informationPERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES
PERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationPARSABIV (etelcalcetide)
PARSABIV (etelcalcetide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationDRUG TESTING IN PAIN MANAGEMENT AND SUBSTANCE USE DISORDER(S) TREATMENT
TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationTREATMENTS FOR GAUCHER DISEASE
TREATMENTS FOR GAUCHER DISEASE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationSOMATULINE DEPOT (lanreotide acetate)
SOMATULINE DEPOT (lanreotide acetate) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationGATTEX (teduglutide [rdna origin])
GATTEX (teduglutide [rdna origin]) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationThe Medical Letter. on Drugs and Therapeutics
The Medical Letter publications are protected by US and international copyright laws. Forwarding, copying or any other distribution of this material is strictly prohibited. For further information call:
More informationTYSABRI FOR CROHN S DISEASE
TYSABRI FOR CROHN S DISEASE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationCOPD Medications Coverage Summary Non-Insured Health Benefits Coverage SABA Bricanyl turbuhaler Yes Yes
COPD Medications Coverage Summary Drug Non-Insured Health Benefits Coverage SABA Bricanyl turbuhaler Yes Yes Ventolin MDI + generics Yes Yes Ventolin Diskus NO NO Yukon Pharmacare/Chronic Disease Program
More informationTYMLOS (abaloparatide)
TYMLOS (abaloparatide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationORAL IMPLANT PROCEDURES
ORAL IMPLANT PROCEDURES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationRADIOFREQUENCY ABLATION OF MISCELLANEOUS SOLID TUMORS EXCLUDING LIVER TUMORS
EXCLUDING LIVER TUMORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationINTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION
INTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationDrug Class Monograph
Drug Class Monograph Class: Inhaled Corticosteroids Drugs: Aerospan (flunisolide), Advair Diskus, Advair HFA (fluticasone/salmeterol), Alvesco (ciclesonide), Arnuity Ellipta (fluticasone furoate), Asmanex
More informationCOPD Update. Plus New and Improved Products for Inhaled Therapy. Catherine Bourg Rebitch, PharmD, BCACP Clinical Associate Professor
COPD Update Plus New and Improved Products for Inhaled Therapy Catherine Bourg Rebitch, PharmD, BCACP Clinical Associate Professor Disclosure The presenter has nothing to disclose concerning possible financial
More informationINTRAVITREAL IMPLANTS
INTRAVITREAL IMPLANTS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationVYXEOS (daunorubicin and cytarabine)
VYXEOS (daunorubicin and cytarabine) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationBONIVA (ibandronate sodium)
BONIVA (ibandronate sodium) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationPROTEOMIC TESTING FOR SYSTEMIC THERAPY IN NON-SMALL-CELL LUNG CANCER
CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationAsthma Management Updates: A Focus on Long-acting Muscarinic Antagonists and Intermittent Inhaled Corticosteroid Dosing
Asthma Management Updates: A Focus on Long-acting Muscarinic Antagonists and Intermittent Inhaled Corticosteroid Dosing Diana M. Sobieraj, PharmD, BCPS Assistant Professor University of Connecticut School
More informationCONTINUOUS OR INTERMITTENT GLUCOSE MONITORING IN INTERSTITIAL FLUID
FLUID Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent
More informationFECAL ANALYSIS IN THE DIAGNOSIS OF INTESTINAL DYSBIOSIS
FECAL ANALYSIS IN THE DIAGNOSIS OF INTESTINAL DYSBIOSIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationBRINEURA (cerliponase alfa)
BRINEURA (cerliponase alfa) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationA Visual Approach to Simplifying Respiratory Drug Regimens
A Visual Approach to Simplifying Respiratory Drug Regimens Stephanie Cheng, PharmD, MPH, BCGP 3 Main Categories Inhaled Respiratory Drugs Binds to beta-2 receptors Relaxation of smooth muscles in the lung
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
HYDROXYPROGESTERONE THERAPY Makena (hydroxyprogesterone caproate injection) Hydroxyprogesterone caproate compound Hydroxyprogesterone caproate injection with benzyl benzoate and the preservative benzyl
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Fasenra) Reference Number: CP.PHAR.## Effective Date: 01.16.18 Last Review Date: 05.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy
More informationClinical Policy: Roflumilast (Daliresp) Reference Number: CP.PMN.46 Effective Date: Last Review Date: 08.18
Clinical Policy: (Daliresp) Reference Number: CP.PMN.46 Effective Date: 11.01.11 Last Review Date: 08.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important
More informationNEGATIVE PRESSURE WOUND THERAPY
NEGATIVE PRESSURE WOUND THERAPY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationMULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER
MULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationNOVEL BIOMARKERS IN RISK ASSESSMENT AND MANAGEMENT OF CARDIOVASCULAR DISEASE
CARDIOVASCULAR DISEASE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationQUANTITY LIMIT CRITERIA. BROVANA (arformoterol tartrate) SEREVENT DISKUS (salmeterol) STRIVERDI RESPIMAT (olodaterol)
Carelirst. +.V Family of health care plans DRUG CLASS COMBINATIONS QUANTITY LIMIT CRITERIA LONG ACTING BETA2-ADRENERGIC AGONIST, ORAL INHALATION BRAND NAME (generic) LONG-ACTING BETA2-ADRENERGIC AGONISTS:
More informationCOSENTYX (secukinumab)
COSENTYX (secukinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Nucala) Reference Number: CP.PHAR.200 Effective Date: 04.01.16 Last Review Date: 02.18 Line of Business: Commercial, Medicaid Coding Implications Revision Log See Important Reminder at
More informationACTEMRA (tocilizumab)
ACTEMRA (tocilizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationGENETIC TESTING FOR HEREDITARY HEARING LOSS
GENETIC TESTING FOR HEREDITARY HEARING LOSS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationFerris State University College of Pharmacy MPA CE Symposium 2016 Paul Thill, PharmD, BCPS
Ferris State University College of Pharmacy MPA CE Symposium 2016 Paul Thill, PharmD, BCPS Objectives Categorize the new asthma and COPD inhalers in to existing or newly created categories Discuss the
More information12/18/2017. Disclosures. Asthma Management Updates: A Focus on Long-acting Muscarinic Antagonists and Intermittent Inhaled Corticosteroid Dosing
Asthma Management Updates: A Focus on Long-acting Muscarinic Antagonists and Intermittent Inhaled Corticosteroid Dosing Diana M. Sobieraj, PharmD, BCPS Assistant Professor University of Connecticut School
More informationNUTRIENT OR NUTRITIONAL PANEL TESTING
NUTRIENT OR NUTRITIONAL PANEL TESTING Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationDUPIXENT (dupilumab) subcutaneous injection
DUPIXENT (dupilumab) subcutaneous injection Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy
More informationINTRACAVITARY BALLOON BRACHYTHERAPY FOR MALIGNANT AND METASTATIC BRAIN TUMORS
METASTATIC BRAIN TUMORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationCARDIOVASCULAR RISK PANELS
CARDIOVASCULAR RISK PANELS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationOPTICAL COHERENCE TOMOGRAPHY (OCT) OF THE MIDDLE EAR
OPTICAL COHERENCE TOMOGRAPHY (OCT) OF THE MIDDLE EAR Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationGENETIC TESTING FOR MARFAN SYNDROME, THORACIC AORTIC ANEURYSMS AND DISSECTIONS AND RELATED DISORDERS
AND DISSECTIONS AND RELATED DISORDERS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 11/14/17 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
RADICAVA (edaravone) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationDrug Effectiveness Review Project Summary Report
Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
More informationHEMATOPOIETIC CELL TRANSPLANTATION FOR PRIMARY AMYLOIDOSIS
Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon
More informationH.P. ACTHAR GEL (repository corticotropin injection)
H.P. ACTHAR GEL (repository corticotropin injection) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationA Visual Approach to Simplifying Respiratory Drug Regimens
A Visual Approach to Simplifying Respiratory Drug Regimens Stephanie Cheng, PharmD, MPH, BCGP October 23, 2017 Learning Objectives Be able to list at least 3 major adverse effects of inhaled medications
More informationClinical Policy: Dupilumab (Dupixent) Reference Number: ERX.SPA.49 Effective Date:
Clinical Policy: (Dupixent) Reference Number: ERX.SPA.49 Effective Date: 06.01.17 Last Review Date: 02.19 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationA Visual Approach to Simplifying Respiratory Drug Regimens
Adverse Effects of Inhaled Medications A Visual Approach to Simplifying Respiratory Drug Regimens Stephanie Cheng, PharmD, MPH, BCGP June 28, 2017 Drug Category Beta 2 agonists antagonists Adverse Effects
More informationNon-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.
ERYTHROPOIESIS-STIMULATING AGENTS (ESAs) Epoetin alfa (Epogen, Procrit ) Darbepoetin alfa (Aranesp ) Methoxy polyethylene glycol (PEG) epoetin-beta (Mircera ) Non-Discrimination Statement and Multi-Language
More informationDEEP BRAIN STIMULATION
DEEP BRAIN STIMULATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationDERMATOLOGIC APPLICATIONS OF PHOTODYNAMIC THERAPY
DERMATOLOGIC APPLICATIONS OF PHOTODYNAMIC THERAPY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationCinqair (reslizumab injection for intravenous use)
Cinqair (reslizumab injection for intravenous use) Policy Number: 5.02.522 Last Review: 04/2018 Origination: 04/2016 Next Review: 04/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will
More informationUp in FLAMES: Stable Chronic Obstructive Pulmonary Disease (COPD) Management. Colleen Sakon, PharmD BCPS September 27, 2018
Up in FLAMES: Stable Chronic Obstructive Pulmonary Disease (COPD) Management Colleen Sakon, PharmD BCPS September 27, 2018 Disclosures I have no actual or potential conflicts of interest 2 Objectives Summarize
More informationBALLOON OSTIAL DILATION FOR TREATMENT OF CHRONIC SINUSITIS
BALLOON OSTIAL DILATION FOR TREATMENT OF CHRONIC SINUSITIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,
More informationGENETIC TESTING FOR FANCONI ANEMIA
GENETIC TESTING FOR FANCONI ANEMIA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationBIVENTRICULAR PACEMAKER (CARDIAC RESYNCHRONIZATION THERAPY) FOR THE TREATMENT OF HEART FAILURE
FOR THE TREATMENT OF HEART FAILURE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationPERCUTANEOUS BALLOON KYPHOPLASTY, RADIOFREQUENCY KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION
KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationAsthma/COPD Update with Inhaler Workshop
Asthma/COPD Update with Inhaler Workshop October 8, 2017 Nathan Samsa, DO, Pharm D, RPh, FACOI None Disclosures Agenda Asthma Updates COPD Updates Inhaler Workshop Medication Acronyms SABA: Short acting
More informationGENETIC TESTING FOR FLT3, NPM1 AND CEBPA VARIANTS IN CYTOGENETICALLY NORMAL ACUTE MYELOID LEUKEMIA
CYTOGENETICALLY NORMAL ACUTE MYELOID LEUKEMIA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,
More informationINTERSPINOUS FIXATION (FUSION) DEVICES
INTERSPINOUS FIXATION (FUSION) DEVICES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationGENETIC TESTING FOR NEUROFIBROMATOSIS
GENETIC TESTING FOR NEUROFIBROMATOSIS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More informationClinical Policy: Mepolizumab (Nucala) Reference Number: ERX.SPA.214 Effective Date:
Clinical Policy: (Nucala) Reference Number: ERX.SPA.214 Effective Date: 07.01.16 Last Review Date: 02.19 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationMEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Asthma/COPD P&T DATE 12/14/2017 CLASS:
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Asthma/COPD P&T DATE 12/14/2017 CLASS: LOB: Respiratory Disorders Medi-Cal REVIEW HISTORY (MONTH/YEAR) 12/17,12/16, 5/15,
More informationREVISED RESPIRATORY MEDICATION USE QUESTIONNAIRE
REVISED RESPIRATORY MEDICATION USE QUESTIONNAIRE ID NUMBER: 0a) Date of Collection / / 0b) Staff Code Instructions: This form should be completed during the participant s clinic visit. 1) Are you regularly
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 03/07/18 SECTION: DRUGS LAST REVIEW DATE: 02/19/19 LAST CRITERIA REVISION DATE: ARCHIVE DATE:
FUZEON (enfuvirtide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationTRANSMYOCARDIAL REVASCULARIZATION
TRANSMYOCARDIAL REVASCULARIZATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
More informationNucala (mepolizumab injection for subcutaneous use)
Nucala (mepolizumab injection for subcutaneous use) Policy Number: 5.01.612 Last Review: 01/2018 Origination: 02/2016 Next Review: 02/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will
More informationGENE EXPRESSION PROFILING AND PROTEIN BIOMARKERS FOR PROSTATE CANCER MANAGEMENT
CANCER MANAGEMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationMDI Bonanza. Dwayne Griffin, DO
MDI Bonanza Dwayne Griffin, DO Bonanza 3. A MDI costing $200 - $500 per month SISYPHUS MDI Griffin Mountain Evolution of Deliver Systems for COPD in the US 2003 2009 2011 2013 2004 2012 2014 Prescribing
More informationMEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 12/19/17 SECTION: MEDICINE LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:
MEDICAL FOODS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are
More information