Pharmacy Medical Policy Bisphosphonates and Monoclonal Antibodies, Infusion/Injection

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1 Pharmacy Medical Policy Bisphosphonates and Monoclonal Antibodies, Infusion/Injection Table of Contents Policy: Commercial Policy History References Coding Information Information Pertaining to All Policies Forms Policy Number: 061 BCBSA Reference Number: None Related Policies None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Note: All requests for outpatient retail pharmacy for indications listed and not listed on the medical policy guidelines may be submitted to BCBSMA Clinical Pharmacy Operations by completing the Prior Authorization Form on the last page of this document. Physicians may also call BCBSMA Pharmacy Operations department at (800) to request a prior authorization/formulary exception verbally. Physicians may also submit requests for retail pharmacy exceptions via the web using Express PAth which can be found on the BCBSMA provider website or directly on the web at Patients must have pharmacy benefits under their subscriber certificates. Note: Reclast and Zometa are not covered under the retail pharmacy benefit and must be billed under the medical benefit. We cover Boniva (ibandronate) and Reclast (zoledronic acid) for a documented diagnosis of osteoporosis in women or men when one of the following criteria is met: Previous treatment failure with one or more oral bisphosphonates (alendronate, Fosamax, Actonel) resulting in intolerability to the oral product Inability to swallow Inability to remain in an upright position during post oral bisphosphonate administration. We cover Reclast (zoledronic acid) for a documented diagnosis of Paget s disease of the bone and for prevention of osteoporosis/osteopenia. We cover Prolia (denosumab) for a documented diagnosis of osteoporosis in postmenopausal women when one of the following criteria is met: Previous treatment failure with one or more oral bisphosphonates (alendronate, Fosamax, Actonel) resulting in intolerability to the oral product

2 Inability to swallow Inability to remain in an upright position during post oral bisphosphonate administration. We cover Prolia (denosumab) for the treatment of androgen deprivation-induced bone loss in men with prostate cancer. We cover Prolia (denosumab) for the treatment of aromatase inhibitor-induced bone loss in women with breast cancer. We cover Xgeva (denosumab) for the prevention of skeletal related events in bone metastases from solid tumors. We cover Zometa (zoledronic acid) for a documented diagnosis of any of the following: Hypercalcemia of malignancy Multiple myeloma Documented bone metastases from solid tumors. We do not cover the above drugs for other conditions not listed above. Other Information Blue Cross Blue Shield of Massachusetts (BCBSMA*) members (other than Medex ; Blue MedicareRx, Medicare Advantage plans that include prescription drug coverage) will be required to fill their prescriptions for the above medications at one of the providers in our retail specialty pharmacy network, as listed below: Retail Specialty Pharmacy Contact Information: AcariaHealth. Phone: Fax: Website: Accredo Health Group Phone: Fax: Website: Caremark, Inc. Phone: Fax: Website: Individual Consideration All our medical policies are written for the majority of people with a given condition. Each policy is based on medical science. For many of our medical policies, each individual s unique clinical circumstances may be considered in light of current scientific literature. Physicians may send relevant clinical information for individual patients for consideration to: Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department One Enterprise Drive

3 Quincy, MA Tel: Fax: Managed Care Authorization Instructions Prior authorization is required for all out patient sites of service For retail pharmacy requests, physicians may call BCBSMA Pharmacy Operations department to request a review for prior authorization for patients. Pharmacy Operations: (800) For all outpatient sites of service, physicians may also fax or mail the attached form to the address above. The Formulary Exception/Prior Authorization form is included as part of this document for physicians to submit for patients. For all outpatient sites of service, physicians may also submit requests for retail pharmacy exceptions via the web using Express PAth which can be found on the BCBSMA provider website or directly on the web at PPO and Indemnity Authorization Instructions Prior authorization is required when these medications are processed under the retail pharmacy benefit and home infusion therapy benefit. Prior authorization is not required when these drugs are purchased by the physician and administered in the office in accordance with this medical policy. For retail pharmacy requests, physicians may call BCBSMA Pharmacy Operations department to request a review for prior authorization for patients. Pharmacy Operations: (800) Physicians may also fax or mail the attached form to the address above. The Formulary Exception/Prior Authorization form is included as part of this document for physicians to submit for patients. Physicians may also submit requests for retail pharmacy exceptions via the web using Express PAth which can be found on the BCBSMA provider website or directly on the web at CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes There is no specific CPT code for this service. HCPCS Codes HCPCS codes: J0897 J1740 Diagnosis coding ICD-9-CM Code Description Injection, denosumab, 1 mg ((Prolia and Xgeva) Injection, ibandronate sodium, 1 mg. (Boniva) diagnosis codes: Code Description Secondary malignant neoplasm of bone and bone marrow Multiple myeloma, without mention of having achieved remission Multiple myeloma, in remission

4 Multiple myeloma, in relapse Hypercalcemia Osteitis deformans without mention of bone tumor Osteoporosis, unspecified Senile osteoporosis Idiopathic osteoporosis Disuse osteoporosis Other osteoporosis Disorder of bone and cartilage, unspecified ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description C79.51 Secondary malignant neoplasm of bone C79.52 Secondary malignant neoplasm of bone marrow C90.00 Multiple myeloma not having achieved remission C90.01 Multiple myeloma in remission C90.02 Multiple myeloma in relapse E83.52 Hypercalcemia M81.0 Age-related osteoporosis without current pathological fracture M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological fracture M85.9 Disorder of bone density and structure, unspecified M88.0 Osteitis deformans of skull M88.1 Osteitis deformans of vertebrae M Osteitis deformans of right shoulder M Osteitis deformans of left shoulder M Osteitis deformans of unspecified shoulder M Osteitis deformans of right upper arm M Osteitis deformans of left upper arm M Osteitis deformans of unspecified upper arm M Osteitis deformans of right forearm M Osteitis deformans of left forearm M Osteitis deformans of unspecified forearm M Osteitis deformans of right hand M Osteitis deformans of left hand M Osteitis deformans of unspecified hand M Osteitis deformans of right thigh M Osteitis deformans of left thigh M Osteitis deformans of unspecified thigh M Osteitis deformans of right lower leg M Osteitis deformans of left lower leg M Osteitis deformans of unspecified lower leg M Osteitis deformans of right ankle and foot M Osteitis deformans of left ankle and foot M Osteitis deformans of unspecified ankle and foot M88.88 Osteitis deformans of other bones M88.89 Osteitis deformans of multiple sites M88.9 Osteitis deformans of unspecified bone Policy History Date Action

5 7/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/ /2014 Removal of Curascripts from Specialty Pharmacy section. 1/2014 Updated to remove deleted HCPCS code J3487 and J /2013 Updated 1/2013 to include new FDA approved indications for Prolia. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements. 1/2012 Updated to include MED UM requirements for Prolia and Xgeva. 7/2011 Updated to include coverage criteria for new FDA approved medication Xgeva. 5/2011 Updated to include coverage criteria for FDA approved indication of osteopenia for Reclast. 1/1/2011 Updated to include coverage criteria for new FDA approved medication Prolia. 10/2009 Updated to reflect UM requirements. 1/1/2009 New policy, effective 1/1/2009, describing covered and non-covered indications. References 1. Boniva injection [package insert]. Nutley, NJ: Roche Laboratories; February Reclast injection [package insert[. East Hanover, NJ: Novartis; August Zometa injection [package insert]. East Hanover, NJ: Novartis; September Reid IR, Miller P, Lyles K, et al. Comparison of a single infusion of zoledronic acid with risedronate for Paget s disease. N Engl J Med (9): Management of osteoporosis in postmenopausal women: 2006 position statement of the North American Menopause Society. Menopause. 2006;13: National Osteoporosis Foundation. Physician s guide to prevention and treatment of osteoporosis. Pharmacologic Options. Washington, D.C.; Updated September Devogelaer JP, Goemaere S, Boonen S, et al. Evidence-based guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis: a consensus document by the Belgian Bone Club. Osteoporosis Int. 2006;17: Whyte MP. Paget s disease of bone. N Engl J Med. 2006;355: Siris ES, Lyles KW, Singer FR, Meunier PJ. Medical management of Paget s disease of bone: indications for treatment and review of current therapies. J Bone Miner Res. 2006;21 Suppl 2:P94-P Black DM, Delmas PD, Eastell R, et al, for the HIZON Pivotal Fracture Trial. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med. 2007;356(18): Lyles KW, Colon-Emeric CS, Magaziner JS, et al, for the HIZON Recurrent Fracture Trial. Zoledronic acid and clinical fractures and mortality after hip surgery. N Engl J Med. 2007;357(18): McClung M, Recker R, Miller P, et al. Intravenous zoledronic acid 5 mg in the treatment of postmenopausal women with low bone density previously treated with alendronate. Bone. 2007;41: Hosking D, Lyles K, Brown JP, et al. Long-term control of bone turnover in Paget s disease with zoledronic acid and risedronate. J Bone Miner Res. 2007;22(1): Delmas PD, Adami S, Strugala C, et al. Intravenous ibandronate injections in postmenopausal women with osteoporosis. One-year results from the dosing intravenous administration study. Arthritis Rheum. 2006;54(6): Ringe JD, Dorst A, Faber H, et al. Intermittent intravenous ibandronate injections reduce vertebral fractures risk in corticosteroid-induced osteoporosis: results from a long-term comparative study. Osteoporosis Int. 2003;14(10): Lamy O, Sandini L, Pache I, et al. Intravenous ibandronate in men with osteoporosis: an open pilot study over 2 years. J Endocrinol Invest. 2003;26(8): Emkey RD, Ettinger M. Improving compliance and persistence with bisphosphonate therapy for osteoporosis. Am J Med. 2006;119(4A):18S-24S. 18. Cooper A, Drake J, Brankin E, on behalf of the persist investigators. Treatment persistence with oncemonthly ibandronate and patient support vs. once-weekly alendronate: results form the PERSIST study. Int J Clin Pract. 2006;60(8): Aredia injection [package insert]. East Hanover, NJ: Novartis Pharmaceuticals; Michaelson MD, Kaufman DS, Lee H, et al. Randomized controlled trial of annual zoledronic acid to prevent gonadotropin-releasing hormone agonist-induced bone loss in men with prostate cancer. J Clin Oncol. 2007;25(9):

6 21. Brufsky A, Harker WG, Beck JT, et al. Zoledronic acid inhibits adjuvant letrozole-induced bone loss in postmenopausal women with early breast cancer. J Clin Oncol. 2007;25(7): Gnant MF, Mlineritsch B, Luschin-Ebengreuth G, et al. Zoledronic acid prevents cancer treatment-induced bone loss in premenopausal women receiving adjuvant endocrine therapy for hormone-responsive breast cancer: a report from the Austrian Breast and Colorectal Cancer Study Group. J Clin Oncol. 2007;25(7): D Souza AB, Grigg AP, Szer J, Ebeling PR. Zoledronic acid prevents bone loss after allogeneic haemopoietic stem cell transplantation. Intern Med J. 2006;36(9): Ringe JD, Farahmand P. Advances in the management of corticosteroid-induced osteoporosis with bisphosphonates. Clin Rheumatol. 2007;26(4): Keating GM, Scott LJ. Zoledronic acid: a review of its use in the treatment of Paget s disease of bone. Drugs. 2007;67(5): Guay DR. Ibandronate, an experimental intravenous bisphosphonate for osteoporosis, bone metastases, and hypercalcemia of malignancy. Pharmacotherapy. 2006;26(5): Kyle RA, Yee GC, Somerfield MR, et al. American Society of Clinical Oncology 2007 clinical practice guidelines update on the role of bisphosphonates in multiple myeloma. J Clin Oncol. 2007;25(17): Prolia injection [package insert]. Thousand Oaks, CA: Amgen Manufacturing Limited; June Xgeva [package insert]. Thousand Oaks, CA: Amgen Manufacturing Limited; November 2010.

7 Request for Outpatient Retail Pharmacy Prior Authorization Fax to: Clinical Pharmacy Program (800) Phone Authorization (800) or Web: We plan to respond to your request within two business days of our receipt. To ensure that we can confirm your request (required by NCQA), please be sure to include your fax number. We cannot process requests unless they contain all of the information requested below: Patient Information (REQUIRED) Name BCBSMA ID Number Is the patient a BCBSMA employee? If yes, please fax request to: (617) Date of Birth Patient s Diagnosis or ICD-9-CM code Physician Information (REQUIRED) Name Medical Specialty BCBSMA Provider number/npi number Telephone Number Fax Number Is this fax number secure for PHI receipt/transmission per HIPAA requirements? (circle one) Yes Contact Name (if different from physician) Please select one of the three following sections to complete, depending on the nature of your request for the above-named patient. Formulary Exception Request Name of non-covered drug you want to prescribe Reason for Individual Consideration Request (please check one): Treatment failure with the following covered drugs in class Documented adverse reaction to the following covered drugs Other clinical reason (please specify) Quality Care Dosing Override Request Drug name, strength and quantity requested: Clinical reason for override (please specify) Outpatient Retail Pharmacy Prior Authorization Request Drug name: Start/End date (must be one year or less): Associated Co-morbid diagnosis: MD Signature: Date: Yes No No

8 Servicing Provider Phone# Fax# Outpatient Medical Prior Authorization Form Please complete and fax to: (888) Please contact Pharmacy Operations with questions at (800) If the patient is a BCBSMA employee, please fax the form to: (617) Name: NPI Number: Requesting Provider Phone# Fax# Name: NPI Number: Contact Person: Contact Person: Patient Name: DOB / / Diagnosis: Patient BCBSMA ID# Is this fax number secure for PHI receipt/transmission per HIPAA requirements? (circle one) Yes No Drug/Therapy: Drug Name: Dates of Service: / / to / / Dose: Frequency: Additional Clinical (including previous treatment failure): Physician signature: Date: 1

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