Drug Therapy Guidelines
|
|
- Veronica Thompson
- 5 years ago
- Views:
Transcription
1 Drug Therapy Guidelines Orencia (abatacept) Applicable Medical Benefit x Effective: 2/21/18 Pharmacy- Frmulary 1 x Next Review: 12/18 Pharmacy- Frmulary 2 x Date f Origin: 11/28/06 Pharmacy- Frmulary 3/Exclusive x Review Dates: 11/28/06, 7/2/07, 11/5/07, 12/15/08, 12/09, 1/11, Pharmacy- Frmulary 4/AON x 9/11, 12/11, 12/12, 12/13, 12/14, 12/15, 12/16, 12/17 I. Medicatin Descriptin Abatacept, a selective c-stimulatin mdulatr, inhibits T-cell (T-lymphcyte) activatin by binding t CD80 and CD86, thereby blcking interactin with CD28. This interactin prvides a c-stimulatry signal necessary fr full activatin f T-lymphcytes. Activated T-lymphcytes are implicated in the pathgenesis f Rheumatid Arthritis (RA) and are fund in the synvium f patients with RA. T-cell prliferatin leads t increased prductin f the cytkines TNF-alpha, interfern-gamma, and interleukin which increases inflammatin and jint destructin. Abatacept s inhibitry actin n these cytkines suppresses inflammatin, decreases anticllagen antibdy prductin, and reduces antigen-specific prductin f interfern-gamma. II. Psitin Statement Cverage is determined thrugh a prir authrizatin prcess with supprting clinical dcumentatin fr every request. When administered subcutaneusly, Orencia is cnsidered a pharmacy benefit. When administered intravenusly, Orencia is cnsidered a medical benefit. III. Plicy Medical Benefit: See Sectin A and C Frmulary 1: See Sectin B and C Frmulary 2: See Sectin B and C Frmulary 3/Exclusive: See Sectin B and C Frmulary 4/AON: See Sectin B and C A. Cverage f intravenus Orencia under the medical benefit is prvided fr the fllwing cnditins when the listed criteria are met: Juvenile idipathic arthritis: Prescribed by a rheumatlgist AND Member has tried therapy with at least ne nn-bilgic DMARD with either treatment failure after 12 weeks r intlerable side effects (unless DMARDs are cntraindicated) AND Member has received at least a 3 mnth trial and failed n at least 1 plan-preferred selfinjectable TNF-α inhibitr (Enbrel r Humira) Psriatic arthritis (active disease): Prescribed by a rheumatlgist r dermatlgist AND One f the fllwing: Page 1 f 5
2 Member has tried therapy with at least ne nn-bilgic DMARD with either treatment failure after 12 weeks r intlerable side effects (unless DMARDs are cntraindicated) OR If predminantly axial disease is dcumented, the member has experienced treatment failure with at least tw ral NSAIDs (unless NSAIDs are cntraindicated) AND Member has first attempted therapy with a plan-preferred medicatin (Remicade r Simpni Aria) Rheumatid arthritis (mderate t severe disease): Prescribed by a rheumatlgist AND Member has tried therapy with at least ne nn-bilgic DMARD with either treatment failure after 12 weeks r intlerable side effects (unless DMARDs are cntraindicated) AND Member has first attempted therapy with a plan-preferred medicatin (Remicade r Simpni Aria) B. Cverage f subcutaneus Orencia under the pharmacy benefit is prvided fr the fllwing cnditins when the listed criteria are met: Juvenile idipathic arthritis: Prescribed by a rheumatlgist AND Member has tried therapy with at least ne nn-bilgic DMARD with either treatment failure after 12 weeks r intlerable side effects (unless DMARDs are cntraindicated) AND Member has received at least a 3 mnth trial and failed n at least 1 plan-preferred selfinjectable TNF-α inhibitr (Enbrel r Humira) Psriatic arthritis (active disease): Prescribed by a rheumatlgist r dermatlgist AND One f the fllwing: Member has tried therapy with at least ne nn-bilgic DMARD with either treatment failure after 12 weeks r intlerable side effects (unless DMARDs are cntraindicated) OR If predminantly axial disease is dcumented, the member has experienced treatment failure with at least tw ral NSAIDs (unless NSAIDs are cntraindicated) AND Member has first attempted therapy with TWO plan-preferred medicatins (Csentyx, Enbrel, Humira, r Stelara) Rheumatid arthritis (mderate t severe disease): Prescribed by a rheumatlgist AND Member has tried therapy with at least ne nn-bilgic DMARD with either treatment failure after 12 weeks r intlerable side effects (unless DMARDs are cntraindicated) AND The member has tried at least TWO f the fllwing plan-preferred medicatins (Actemra, Humira, Enbrel, r Xeljanz/Xeljanz XR) C. Step therapy criteria utlined in A and B apply unless the fllwing criteria are met: When requesting cverage f a brand medicatin fr which an A/B rated generic is available, there is sufficient evidence that the use f the A/B rated generic equivalent has resulted in inadequate results AND At least ne f the fllwing is met: The plan-preferred medicatins are cntraindicated r will likely cause an adverse reactin by r physical r mental harm t the member. Page 2 f 5
3 The plan-preferred medicatins are expected t be ineffective based n the knwn clinical histry and cnditins f the member and the member s prescriptin drug regimen. The member has tried the plan-preferred medicatins r anther prescriptin drug in the same pharmaclgic class r with the same mechanism f actin and such prescriptin drug was discntinued due t lack f efficacy r effectiveness, diminished effect, r an adverse event. The member is stable n the medicatin selected by their healthcare prfessinal fr the medical cnditin under cnsideratin (where stable is defined as receiving the medicatin fr an adequate perid f time, have achieved ptimal respnse, and cntinued favrable utcmes are expected UNLESS the medicatin was initially selected due t the availability f a drug sample r a cupn card). The plan-preferred medicatin is nt in the best interest f the member because it will likely cause a significant barrier t the member s adherence r t cmpliance with the member s plan f care, will likely wrsen a cmrbid cnditin f the member, r will likely decrease the member s ability t achieve r maintain reasnable functinal ability in perfrming daily activities. IV. Quantity Limits Cverage fr intravenus dsing is available as fllws: Fr the treatment f juvenile idipathic arthritis: Members 6 years and lder weighing mre than 100 kg: 3000 mg in the first 28 days f therapy, then starting at week 8, 1000mg every 28 days thereafter Members 6 years and lder weighing 75 kg t 100 kg: 2250 mg in the first 28 days f therapy, then starting at week 8, 750 mg every 28 days thereafter Members 6 years and lder weighing less than 75 kg: three 10 mg/kg dses in the first 28 days f therapy, then starting at week 8, 10 mg/kg every 28 days thereafter Fr the treatment f psriatic and rheumatid arthritis: Members 18 years and lder weighing mre than 100 kg: 3000 mg in the first 28 days f therapy, then starting at week 8, 1000mg every 28 days thereafter Members 18 years and lder and weighing 60 kg t 100 kg: 2250 mg in the first 28 days f therapy, then starting at week 8, 750 mg every 28 days thereafter Members 18 years f age and lder weighing less than 60 kg: 1500 mg in the first 28 days f therapy, then starting at week 8, 500 mg every 28 days thereafter Cverage fr subcutaneus dsing is available as fllws: Fr the treatment f juvenile idipathic arthritis: Members 2 years and lder weighing 50 kg r mre: fur 125 mg syringes r autinjectrs per each 28 days Members 2 years and lder weighing 25 kg t less than 50 kg: fur 87.5 mg syringes per each 28 days Members 2 years and lder weighing 10 kg t less than 25 kg: fur 50 mg syringes per each 28 days Page 3 f 5
4 Fr the treatment f psriatic and rheumatid arthritis: Members 18 years and lder: fur 125mg syringes r autinjectrs per each 28 days V. Cverage Duratin Cverage is prvided fr 12 mnths and may be renewed. VI. Cverage Renewal Criteria Cverage can be renewed based upn the fllwing criteria: Clinical respnse r remissin f disease is maintained with cntinued use AND Absence f unacceptable txicity frm the drug VII. Billing/Cding Infrmatin J billable unit is 10mg Available as: Orencia 250 mg lyphilized pwder in a single use vial fr recnstitutin prir t intravenus infusin Orencia single dse prefilled syringes fr subcutaneus use (prvided in a packs f 4 syringes): 50 mg/0.4 ml 87.5 mg/0.7 ml 125 mg/ml Orencia (single dse prefilled ClickJect autinjectr)- 125 mg/ml syringe fr subcutaneus use, prvided in a pack f 4 autinjectrs Pertinent diagnses: Juvenile rheumatid arthritis: M08.00, M08.3, M08.40 Psriatic Arthritis: L L40.53, L40.59 Rheumatid arthritis: M05.00, M05.30, M05.60, M06.1, M06.9 VIII. Summary f Plicy Changes 1/2011: Clarificatin f prir DMARD use requirements Clarificatin f plan-preferred medicatins: Humira and Enbrel 6/15/12: Additin f Orencia SC criteria fr cverage; Additin f Orencia SQ / prefilled syringe dsing and prduct infrmatin t guideline Cverage duratin extended t 12 mnths 3/15/13: n changes 7/1/13: Medical, Cmmercial Rx, and Medicaid/FHP Rx criteria differentiated 3/15/13: clarified need fr latent Tb testing Page 4 f 5
5 8/1/14: Cverage fr the treatment f RA under the medical benefit requires the use f either Remicade r Simpni Aria first 3/15/14: n plicy changes 7/1/15: frmulary distinctins made 3/15/16: n plicy changes 1/1/17: step therapy rules updated n the pharmacy benefit 5/1/17: step therapy criteria added 10/20/17: cverage f Orencia fr the treatment f psriatic arthritis added; available prducts and quantity limits updated 1/1/18: n plicy changes IX. References 1. Up-t-date Online, retrieved Nvember Clinical Pharmaclgy Online, retrieved Nvember 2017 ( 3. Facts and Cmparisns Online, retrieved Nvember Prduct Infrmatin: Orencia (Abatacept). Bristl-Myers Squibb. Revised 6/ Genvese MC, Cvarrubias A, et al. Subcutaneus Abatacept Versus Intravenus Abatacept: A phase IIIb nn-inferirity study in patients with an inadequate respnse t methtrexate. Arthritis Rheum 2011 Oct;63(10): di: /art Genvese MC, Schiff M, et al. Efficacy and safety f the selective c-stimulatin mdulatr Abatacept fllwing 2 years f treatment in patients with rheumatid arthritis and an inadequate respnse t antitumur necrsis factr therapy. Ann Rheum Dis 2008;67: Remy A, Avuac J, et al. Clinical relevance f switching t a secnd tumur necrsis factr-alpha inhibitr in rheumatid arthritis: A systematic literature review and meta-analysis. Clin Exp Rheumatl 2011; 29: The Plan fully expects that nly apprpriate and medically necessary services will be rendered. The Plan reserves the right t cnduct pre-payment and pst-payment reviews t assess the medical apprpriateness f the abve-referenced therapies. The preceding plicy applies nly t members fr whm the abve named pharmacy benefit medicatins are included n their cvered frmulary. Members with clsed frmulary benefits are subject t trying all apprpriate frmulary alternatives befre a cverage exceptin fr a nn-frmulary medicatin will be cnsidered. The preceding plicy is a guideline t allw fr cverage f the pertinent medicatin/prduct, and is nt meant t serve as a clinical practice guideline. Page 5 f 5
Drug Therapy Guidelines
Applicable* Medical Benefit x Effective: 2/15/19 Pharmacy- Frmulary 1 Next Review: 12/19 Pharmacy- Frmulary 2 Date f Origin: 4/1/05 Pharmacy- Frmulary 3/Exclusive Review Dates: 4/1/05, 2/1/06, 10/15/06,
More informationDrug Therapy Guidelines
Drug Therapy Guidelines Applicable* Hereditary Angiedema (HAE) Agents: Berinert (C1 esterase inhibitr [human]), Cinryze (C1 esterase inhibitr [human]), Haegarda (C1 esterase inhibitr [human]) Kalbitr (ecallantide),
More informationDrug Therapy Guidelines
Applicable Medical Benefit x Effective: 5/1/18 Pharmacy- Frmulary 1 x Next Review: 3/18 Pharmacy- Frmulary 2 x Date f Origin: 4/99 Gnadtrpin-Releasing Hrmne Agnists- Eligard, Luprn, Luprn-Dept, Luprn Dept-Ped,
More informationDrug Therapy Guidelines
Simponi, Simponi Aria Applicable Medical Benefit x Effective: 2/13/18 Pharmacy- Formulary 1 x Next Review: 12/18 Pharmacy- Formulary 2 x Date of Origin: 7/2010 Pharmacy- Formulary 3/Exclusive x Review
More informationOrencia (abatacept) Document Number: MODA-0091
Orencia (abatacept) Dcument Number: MODA-0091 Last Review Date: 09/19/2017 Date f Origin: 07/02/2010 Dates Reviewed: 07/2010, 09/2010, 12/2010, 02/15/11, 03/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012,
More informationNew Exception Status Benefits
FEBRUARY 2019 Nva Sctia Frmulary Updates New Exceptin Status Benefits Prcysbi (cysteamine bitartrate) Nucala (meplizumab) Ocaliva (betichlic acid) Ravicti (glycerl phenylbutyrate) Taltz (ixekizumab) Criteria
More informationRituxan (rituximab) Effective Date: 10/01/2015. Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage
Rituxan (rituximab) Line(s) f Business: HMO; PPO; QUEST Integratin Akamai Advantage Effective Date: 10/01/2015 POLICY A. INDICATIONS The indicatins belw including FDA-apprved indicatins and cmpendial uses
More informationDrug Therapy Guidelines
Applicable Medical Benefit x Effective: 1/1/18 Pharmacy- Frmulary 1 x Next Review: 12/18 Pharmacy- Frmulary 2 x Date f Origin: 5/28/06 Pulmnary Arterial Hypertensin : Revati (sildenafil), Ventavis (ilprst),
More informationOpioid Analgesics PA Request Provider Checklist
WVP Health Authrity Updated 05-12-2015 Opiid Analgesics PA Request Prvider Checklist *** If pssible, please include the fllwing infrmatin with PA requests fr piid analgesics. Including the requested infrmatin
More informationP02-03 CALA Program Description Proficiency Testing Policy for Accreditation Revision 1.9 July 26, 2017
P02-03 CALA Prgram Descriptin Prficiency Testing Plicy fr Accreditatin Revisin 1.9 July 26, 2017 P02-03 CALA Prgram Descriptin Prficiency Testing Plicy fr Accreditatin TABLE OF CONTENTS TABLE OF CONTENTS...
More informationSUMMACARE COMMERCIAL MEDICATION REQUEST GUIDELINES. ANTI-OBESITY AGENTS Generic Brand HICL GCN Exception/Other QSYMIA 32515, 32744, 32746, 32745
Generic Brand HICL GCN Exceptin/Other NALTREXONE CONTRAVE ER 41389 /BUPROPION LORCASERIN BELVIQ 34733 PHENTERMINE PHENTERMINE 20691 20692 20693 20713 PHENTERMINE LOMAIRA 20715 PHENTERMINE/TO PIRAMATE GUIDELINES
More informationClinical Policy: Vedolizumab (Entyvio) Reference Number: ERX.SPA.163 Effective Date:
Clinical Plicy: Vedlizumab (Entyvi) Reference Number: ERX.SPA.163 Effective Date: 10.01.16 Last Review Date: 11.18 Revisin Lg See Imprtant Reminder at the end f this plicy fr imprtant regulatry and legal
More informationCardiac Rehabilitation Services
Dcumentatin Guidance N. DG1011 Cardiac Rehabilitatin Services Revisin Letter A 1.0 Purpse The Centers fr Medicare and Medicaid Services (CMS) has detailed specific dcumentatin requirements fr Cardiac Rehabilitatin
More informationWound Care Equipment and Supply Benefits to Change for Texas Medicaid July 1, 2018
Wund Care Equipment and Supply Benefits t Change fr Texas Medicaid July 1, 2018 Infrmatin psted May 11, 2018 Nte: Texas Medicaid managed care rganizatins (MCOs) must prvide all medically necessary, Medicaid-cvered
More informationDrug Therapy Guidelines
Drug Therapy Guidelines Applicable Medical Benefit x Effective: 5/1/18 Pharmacy- Frmulary 1 x Next Review: 6/18 Pharmacy- Frmulary 2 x Date f Origin: 11/07 Immune Glbulins Intravenus: Carimune NF, Flebgamma,
More informationRelated Policies None
Medical Plicy MP 3.01.501 Guidelines fr Cverage f Mental and Behaviral Health Services Last Review: 8/30/2017 Effective Date: 8/30/2017 Sectin: Mental Health End Date: 08/19/2018 Related Plicies Nne DISCLAIMER
More informationRequest for Prior Authorization for Click here to enter text. Website Form Submit request via: Fax
Request fr Prir Authrizatin fr Click here t enter text. Website Frm www.highmarkhealthptins.cm Submit request via: Fax - 1-855-476-4158 Updated: 05/2018 DMMA Apprved: 05/2018 All requests fr Intravenus
More informationHealth Screening Record: Entry Level Due: August 1st MWF 150 Entry Year
Health Screening Recrd: Entry Level MIDWIFERY EDUCATION PROGRAM HEALTH SCREENING REQUIREMENTS (Rev. June 2017) 1. Hepatitis B: Primary vaccinatin series (3 vaccines 0, 1 and 6 mnths apart), plus serlgic
More informationContinuous Positive Airway Pressure (CPAP) and Respiratory Assist Devices (RADs) including Bi-Level PAP
Cntinuus Psitive Airway Pressure (CPAP) and Respiratry Assist Devices (RADs), Including Bi-Level PAP Benefit Criteria t Change fr Texas Medicaid Effective March 1, 2017 Overview f Benefit Changes Benefit
More informationMylotarg (gemtuzumab ozogamicin) (Intravenous)
Myltarg (gemtuzumab zgamicin) (Intravenus) Last Review Date: 09/19/2017 Date f Origin: 09/19/2017 Dates Reviewed: 09/2017 Dcument Number: IC-0320 I. Length f Authrizatin Newly-Diagnsed AML De nv disease
More informationBenefits for Anesthesia Services for the CSHCN Services Program to Change Effective for dates of service on or after July 1, 2008, benefit criteria
Benefits fr Anesthesia Services fr the CSHCN Services Prgram t Change Effective fr dates f service n r after July 1, 2008, benefit criteria fr anesthesia will change fr the Children with Special Health
More informationIntravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion
Intravenus Vancmycin Use in Adults Intermittent (Pulsed) Infusin Backgrund This plicy cvers the use f intravenus vancmycin prescribed as an intermittent (pulsed) infusin. This can be used fr treatment
More informationUS Public Health Service Clinical Practice Guidelines for PrEP
Webcast 1.3 US Public Health Service Clinical Practice Guidelines fr PrEP P R E S ENTED BY: M A R K T H R U N, M D A S S O C I AT E P R O F E S S O R, U N I V E R S I T Y O F C O L O R A D O, D I V I S
More information2017 Optum, Inc. All rights reserved BH1124_112017
1) What are the benefits t clients f encuraging the use f MAT? Withut MAT, 90% f individuals with Opiid Use Disrder (OUD) will relapse within ne year. With MAT, the relapse rate fr thse with OUD decreases
More informationIntravenous Vancomycin Use in Adults Intermittent (Pulsed) Infusion
Backgrund This plicy cvers the use f intravenus vancmycin prescribed as an intermittent (pulsed) infusin. This can be used fr treatment r prphylaxis. Evidence supprting this guidance is detailed belw.
More informationCSHCN Services Program Benefits to Change for Outpatient Behavioral Health Services Information posted November 10, 2009
CSHCN Services Prgram Benefits t Change fr Outpatient Behaviral Health Services Infrmatin psted Nvember 10, 2009 Effective fr dates f service n r after January 1, 2010, benefit criteria fr utpatient behaviral
More informationOriginal Policy Date 12:2013
MP 5.01.18 Xlair (Omalizumab) Medical Plicy Sectin Prescriptin Drugs Issu12:2013e 4:2006 Original Plicy Date 12:2013 Last Review Status/Date Lcal plicy/12:2013 Return t Medical Plicy Index Disclaimer Our
More informationThis Coverage Policy applies to Individual Health Insurance Marketplace benefit plans only.
This Cverage Plicy applies t Individual Health Insurance Marketplace benefit plans nly. Immunlgical Agents Bilgical Respnse Mdifier-Tumr Necrsis Factr (TNF) Inhibitrs: Enbrel (etanercept fr subcutaneus
More informationSubject: Abatacept (Orencia ) Injection and Infusion
09-J0000-67 Original Effective Date: 06/15/07 Reviewed: 09/12/18 Revised: 10/15/18 Subject: Abatacept (Orencia ) Injectin and Infusin THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION,
More informationMethadone Maintenance Treatment for Opioid Dependence
POLICY STATEMENT Methadne Maintenance Treatment fr Opiid Dependence APPROVED BY COUNCIL: May 2010 PUBLICATION DATE: Dialgue, Issue 2, 2010 Disclaimer: As f May 19, 2018 physicians n lnger require an exemptin
More informationo Prostanoids/prostacyclin therapies (oral and inhaled) o Inhaled agents: Ventavis, Tyvaso Page 1 of 5 Revised 02/17/17
Request fr Prir Authrizatin Pulmnary Arterial Hypertensin (PAH) Agents (Oral and Inhaled) Website Frm www.highmarkhealthptins.cm Submit request via: Fax - 1-855-476-4158 All requests fr Pulmnary Arterial
More informationMBP 40.0 Orencia IV (abatacept)- Updated policy
What s New Medical Pharmaceutical Plicy Nvember 2018 Updates MBP 5.0 Remicade (infliximab), Inflectra (infliximab-dyyb), Renflexis (infliximab-abda)- Updated plicy Fr Treatment f Rheumatid Arthritis: Must
More informationWidening of funding restrictions for rituximab and eltrombopag
20 February 2014 Widening f funding restrictins fr rituximab and eltrmbpag PHARMAC is pleased t annunce the apprval f prpsals t widen the restrictin n rituximab use in DHB hspitals and expand the funding
More informationAnnex III. Amendments to relevant sections of the Product Information
Changes t the Prduct infrmatin as apprved by the CHMP n 13 Octber 2016, pending endrsement by the Eurpean Cmmissin Annex III Amendments t relevant sectins f the Prduct Infrmatin Nte: These amendments t
More informationLEVEL OF CARE GUIDELINES: INTENSIVE BEHAVIORAL THERAPY/APPLIED BEHAVIOR ANALYSIS FOR AUTISM SPECTRUM DISORDER HAWAII MEDICAID QUEST
OPTUM LEVEL OF CARE GUIDELINES: INTENSIVE BEHAVIORAL THERAPY / APPLIED BEHAVIOR ANALYSIS FOR AUTISM SPECTRUM DISORDER HAWAII MEDICAID QUEST LEVEL OF CARE GUIDELINES: INTENSIVE BEHAVIORAL THERAPY/APPLIED
More informationCompleting the NPA online Patient Safety Incident Report form: 2016
Cmpleting the NPA nline Patient Safety Incident Reprt frm: 2016 The infrmatin cntained within this dcument is in line with the current Data Prtectin Act (DPA) requirements. This infrmatin may be subject
More informationDrug Therapy Guidelines
Drug Therapy Guidelines Applicable Medical Benefit Effective: 8/15/18 Pharmacy- Frmulary 1 x Next Review: 6/19 Pharmacy- Frmulary 2 x Date f Origin: 10/99 Grwth Stimulating Drugs: Nrditrpin Flexpr, Gentrpin,
More informationPerjeta (pertuzumab) Document Number: IC I. Length of Authorization. Dosing Limits. Initial Approval Criteria
Perjeta (pertuzumab) Last Review Date: 11/21/2017 Date f Origin: 11/01/2012 Dcument Number: IC-0096 Dates Reviewed: 12/2012, 3/2013, 6/2013, 9/2013, 11/2013, 12/2013, 3/2014, 6/2014, 9/2014, 12/2014, 3/2015,
More informationKadcyla (ado-trastuzumab emtansine) Document Number: IC-0092
Kadcyla (ad-trastuzumab emtansine) Dcument Number: IC-0092 Last Review Date: 2/6/2018 Date f Origin: 05/16/2013 Dates Reviewed: 7/2013, 11/2013, 12/2013, 3/2014, 6/2014, 9/2014, 12/2014, 5/2015, 8/2015,
More informationActemra (tocilizumab) (Intravenous)
Actemra (tcilizumab) (Intravenus) Last Review Date: 06/01/2018 Date f Origin: 09/21/2010 Dcument Number: MODA-0002 Dates Reviewed: 12/2010, 03/2011, 05/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012,
More informationTriumeq (abacavir, dolutegravir and lamivudine) Product Backgrounder for US Media
Triumeq (abacavir, dlutegravir and lamivudine) Prduct Backgrunder fr US Media What is Triumeq and wh is Triumeq fr? Triumeq (abacavir 600mg, dlutegravir 50mg and lamivudine 300mg) is the first dlutegravir-based
More informationQ 5: Is relaxation training better (more effective than/as safe as) than treatment as usual in adults with depressive episode/disorder?
updated 2012 Relaxatin training Q 5: Is relaxatin training better (mre effective than/as safe as) than treatment as usual in adults with depressive episde/disrder? Backgrund The number f general health
More informationPennsylvania Guidelines on the Use of Opioids to Treat Chronic Noncancer Pain
Pennsylvania Guidelines n the Use f Opiids t Treat Chrnic Nncancer Pain Chrnic pain is a majr health prblem in the United States, ccurring with a pintprevalence f abut ne-third f the US ppulatin.(1) Mre
More informationNIA Magellan 1 Spine Care Program Interventional Pain Management Frequently Asked Questions (FAQs) For Medicare Advantage HMO and PPO
NIA Magellan 1 Spine Care Prgram Interventinal Pain Management Frequently Asked Questins (FAQs) Fr Medicare Advantage HMO and PPO Questin GENERAL Why is Flrida Blue implementing a Spine Management prgram
More informationBariatric Surgery FAQs for Employees in the GRMC Group Health Plan
Bariatric Surgery FAQs fr Emplyees in the GRMC Grup Health Plan Gergia Regents Medical Center and Gergia Regents Medical Assciates emplyees and eligible dependents wh are in the GRMC Grup Health Plan (Select
More informationCommissioning Policy: South Warwickshire CCG (SWCCG)
Cmmissining Plicy: Suth Warwickshire CCG (SWCCG) Treatment Indicatin Criteria FreeStyle Libre Flash Cntinuus Glucse Mnitring System Type I Diabetes Prir apprval must be requested frm the Individual Funding
More informationFolotyn (pralatrexate)
Fltyn (pralatrexate) Line(s) f Business: HMO; PPO; QUEST Integratin Akamai Advantage Original Effective Date: 10/01/2015 Current Effective Date: 01/01/2018TBD03/01/2017 POLICY A. INDICATIONS The indicatins
More informationReferral Criteria: Inflammation of the Spine Feb
Referral Criteria: Inflammatin f the Spine Feb 2019 1 5.7. Inflammatin f the Spine Backgrund Ankylsing spndylitis and axial spndylarthrpathy are fund in arund 0.3-1.2% f the ppulatin. Spndylarthritis encmpasses
More informationCancer Association of South Africa (CANSA)
Cancer Assciatin f Suth Africa (CANSA) Fact Sheet and Psitin Statement n Cannabis in Suth Africa Intrductin Cannabis is a drug that cmes frm Indian hemp plants such as Cannabis sativa and Cannabis indica.
More informationErythropoiesis Stimulating Agents (ESAs): Aranesp (darbepoetin alfa) Related Medical Guideline Off-Label Use of FDA-Approved Drugs and Biologicals
(Subcutaneus/Intravenus) Last Review Date: January 1, 2019 Number: MG.MM.PH.80 *NON-DIALYSIS* Medical Guideline Disclaimer C All rights reserved. The treating physician r primary care prvider must submit
More informationRegulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.18 Subject: Orencia Page: 1 of 6 Last Review Date: December 8, 2017 Orencia Description Orencia (abatacept)
More informationIndications and Limitations of Coverage and/or Medical back to top
Fr services perfrmed n r after 09/15/2009 Original Determinatin Ending Date Revisin Effective Date Revisin Ending Date Indicatins and Limitatins f Cverage and/r Medical Necessity Indicatins Medicare cverage
More informationHIP REPLACEMENT SURGERY (ARTHROPLASTY)
Prtcl: ORT015 Effective Date: June 1, 2017 HIP REPLACEMENT SURGERY (ARTHROPLASTY) Table f Cntents Page COMMERCIAL & MEDICAID COVERAGE RATIONALE... 1 MEDICARE COVERAGE RATIONALE... 3 U.S.FOOD AND DRUG ADMINISTRATION
More informationNational Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQs) For Managed Health Services (MHS)
Questin GENERAL Why did MHS implement a Medical Specialty Slutins Prgram? Natinal Imaging Assciates, Inc. (NIA) Frequently Asked Questins (FAQs) Fr Managed Health Services (MHS) Answer Effective Nvember
More informationCLINICAL MEDICAL POLICY
Plicy Name: Plicy Number: Respnsible Department(s): CLINICAL MEDICAL POLICY Supervised Exercise Therapy fr Peripheral Artery Disease (PAD) MP-077-MD-DE Medical Management Prvider Ntice Date: 01/15/2019
More informationMeaningful Use Roadmap Stage Edition Eligible Hospitals
Meaningful Use Radmap Stage 1-2011 Editin Eligible Hspitals CPSI is dedicated t making yur transitin t Meaningful Use as seamless as pssible. Therefre, we have cme up with a radmap t assist yu in implementing
More informationBANKMED MEDICAL SCHEME. MEDICINE ADVISORY SERVICES (Chronic Medicine Benefit) GENERAL INFORMATION
BANKMED MEDICAL SCHEME MEDICINE ADVISORY SERVICES (Chrnic Medicine Benefit) GENERAL INFORMATION LIST OF CHRONIC CONDITIONS Cnditins cvered under Bankmed s chrnic medicatin benefit are detailed belw. REGISTRATION
More informationSECTION O. MEDICATIONS
SECTION O. MEDICATIONS 1. NUMBER OF MEDICA TIONS (Recrd the number f different medicatins used in the last 7 days; enter "0" if nne used) O1. Number f Medicatins (7-day lk back) Intent: Prcess: Cding:
More informationSolid Organ Transplant Benefits to Change for Texas Medicaid
Slid Organ Transplant Benefits t Change fr Texas Medicaid Infrmatin psted February 13, 2015 Nte: All new and updated prcedure cdes and their assciated reimbursement rates are prpsed benefits pending a
More informationClinical Study Synopsis
Clinical Study Synpsis This Clinical Study Synpsis is prvided fr patients and healthcare prfessinals t increase the transparency f Bayer's clinical research. This dcument is nt intended t replace the advice
More informationMedical Student Immunization Requirements
Medical Student Immunizatin Requirements The State f Illinis cde, Reference: (110 ILCS 20) Cllege Student Immunizatin Act, requires students t prvide prf f immunity: Measles (Rubela), Mumps, Rubella (German
More informationHigh Performance Network Quality Criteria for Designation
Selected quality measures include: Specialty Measure Descriptin Allergy / Immunlgy Asthma Drug Mgt Vaccine Pneumnia Vaccine High Perfrmance Netwrk Quality Criteria fr Designatin AvMed has selected certain
More informationUNM SRMC SLEEP MEDICINE CLINICAL PRIVILEGES.
Initial privileges (initial appintment) Renewal f privileges (reappintment) Expansin f privileges (mdificatin) INSTRUCTIONS All new applicants must meet the fllwing requirements as apprved by the UNM SRMC
More informationOTHER AND UNSPECIFIED DISORDERS
OPTUM COVERAGE DETERMINATION GUIDELINE OTHER AND UNSPECIFIED DISORDERS Guideline Number: BH727OUD_102017 Effective Date: Octber, 2017 Table f Cntents Page INSTRUCTIONS FOR USE... 1 BENEFIT CONSIDERATIONS...
More informationHEDIS. Healthcare Effectiveness Data & Information Set (HEDIS ) QUALITY MANAGEMENT PROGRAM SECTION 8
HEDIS Healthcare Effectiveness Data & Infrmatin Set (HEDIS ) The HEDIS â audit cntains a cre set f perfrmance measures that prvide infrmatin abut custmer satisfactin, specific health care measures, and
More informationRegulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.18 Subject: Orencia Page: 1 of 8 Last Review Date: March 16, 2018 Orencia Description Orencia (abatacept)
More informationYescarta (axicabtagene ciloleucel) (Intravenous)
Yescarta (axicabtagene cilleucel) (Intravenus) Last Review Date: 10/31/2017 Date f Origin: 10/31/2017 Dates Reviewed: 10/2017 Dcument Number: IC-0333 I. Length f Authrizatin Cverage will be prvided fr
More informationNumber: III-10 Effective Date: Feb 1999
Apprved By: Prvincial Systemic Prgram Cmmittee Revisin Date: Nv 1, 2016; Nv 30, 2017 Page 1 f 11 DIRECTIVE: In rder t ensure the safe prescribing, preparatin, dispensing and administratin f all systemic
More informationNational Imaging Associates, Inc. (NIA) Frequently Asked Questions (FAQs) For Louisiana Healthcare Connections Providers
Natinal Imaging Assciates, Inc. (NIA) Frequently Asked Questins (FAQs) Fr Luisiana Healthcare Cnnectins Prviders Questin GENERAL Why did Luisiana Healthcare Cnnectins implement a Medical Prgram? Answer
More informationLower Extremity Amputation (LEA) Considerations / Issues
Lwer Extremity Amputatin (LEA) Cnsideratins / Issues Prviding Te Fillers can be an advantageus resurce fr yur patient and business but it als cmes with certain cnsideratins. Please review this list belw
More informationSCALES NW HEARING PROTECTION PROGRAM
PURPOSE Expsure t excessive nise in the wrkplace can cause permanent hearing lss. The Hearing Prtectin Prgram has been established t help ensure that emplyees f Scales NW, Inc. d nt suffer health effects
More informationClinical Policy: Corticotropin (H.P. Acthar) Reference Number: ERX.SPA.72 Effective Date:
Clinical Plicy: (H.P. Acthar) Reference Number: ERX.SPA.72 Effective Date: 10.01.16 Last Review Date: 02.18 Revisin Lg See Imprtant Reminder at the end f this plicy fr imprtant regulatry and legal infrmatin.
More informationCorporate Governance Code for Funds: What Will it Mean?
Crprate Gvernance Cde fr Funds: What Will it Mean? The Irish Funds Industry Assciatin has circulated a draft Vluntary Crprate Gvernance Cde fr the Funds Industry in Ireland. 1. Backgrund On 13 June 2011,
More informationCOVERAGE ELIGIBILITY OF SERVICES ASSOCIATED WITH A CANCER CLINICAL TRIAL
TRIAL Nn-Discriminatin Statement and Multi-Language Interpreter Services infrmatin are lcated at the end f this dcument. Cverage fr services, prcedures, medical devices and drugs are dependent upn benefit
More informationStructured Assessment using Multiple Patient. Scenarios (StAMPS) Exam Information
Structured Assessment using Multiple Patient Scenaris (StAMPS) Exam Infrmatin 1. Preparing fr the StAMPS assessment prcess StAMPS is an assessment mdality that is designed t test higher rder functins in
More informationImmunisation and Disease Prevention Policy
Immunisatin and Disease Preventin Plicy Quality Area 2: Children s Health and Safety 2.1 Each child s health is prmted 2.1.4 Steps are taken t cntrl the spread f infectius diseases and t manage injuries
More informationDear Student, IMMUNIZATION RECORD INSTRUCTIONS
Dear Student, Welcme t the University f Chicag! The State f Illinis and University regulatins require students t prvide prf f required immunizatins prir t registratin fr classes. In rder t cmplete this
More informationBreast Cancer Awareness Month 2018 Key Messages (as of June 6, 2018)
Breast Cancer Awareness Mnth 2018 Key Messages (as f June 6, 2018) In this dcument there are tw sectins f messages in supprt f Cancer Care Ontari s Breast Cancer Awareness Mnth 2018: 1. Campaign key messages
More informationSoliris (eculizumab) Document Number: MODA-0114
Sliris (eculizumab) Dcument Number: MODA-0114 Last Review Date: 9/19/2017 Date f Origin: 06/21/2011 Dates Reviewed: 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 03/2014, 06/2014, 09/2014,
More informationSchool Medication Authorization Form. School Grade Teacher. Emergency Phone No: To be completed by the student's physician: Name of Medication:
Schl Medicatin Authrizatin Frm Student's Name Address Birth Date Hme Phne Schl Grade Teacher Emergency Phne N: T be cmpleted by the student's physician: Name f Medicatin: Dsage Frequency Time t be given
More informationPain relief after surgery
Pain relief after surgery Imprtant infrmatin fr patients www.mchft.nhs.uk We care because yu matter This leaflet is designed t help yu cntrl any pain yu may have at hme fllwing yur peratin. Please read
More informationBiologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary Biologic Immunomodulators Prior Authorization with Quantity Limit (with a preferred option) OBJECTIVE The intent of the
More information1.11 INSULIN INFUSION PUMP MANAGEMENT INPATIENT
WOMEN AND NEWBORN HEALTH SERVICE CLINICAL GUIDELINES SECTION A: GUIDELINES RELEVANT TO OBSTETRICS AND GYNAECOLOGY 1 STANDARD PROTOCOLS 1.11 INSULIN INFUSION PUMP MANAGEMENT - INPATIENT Authrised by: OGCCU
More informationPhysical, Occupational, and Speech Therapy - Children (Acute and Chronic)
Physical, Occupatinal, and Speech Therapy - Children (Acute and Chrnic) Infrmatin psted May 6, 2016 Nte: This article applies t claims submitted t TMHP fr prcessing. Fr claims prcessed by a Medicaid managed
More informationQP Energy Services LLC Hearing Conservation Program HSE Manual Section 7 Effective Date: 5/30/15 Revision #:
QP Energy Services LLC Hearing Cnservatin Prgram HSE Manual Sectin 7 Effective Date: 5/30/15 Revisin #: Prepared by: James Aregd Date: 5/30/15 Apprved by: James Aregd Date: 5/30/15 Page 1 f 8 Cntents Sectin
More information2018 Medical Association Poster Symposium Guidelines
2018 Medical Assciatin Pster Sympsium Guidelines Overview The 3 rd Annual student-run Medical Assciatin f the State f Alabama Research Sympsium will take place n Friday and Saturday, April 13-14 at the
More information5.0: Rare Bleeding Disorders
5.0: Rare Bleeding Disrders 5.1: General Infrmatin Rare bleeding disrders (RBDs) include deficiencies f factrs I (Fibringen), II, V, VII, X, XI and XIII. These deficiencies can be severe r mild. Severe
More informationEAGLE CARE A SPORT CLUB CONCUSSION MANAGEMENT MODEL
EAGLE CARE A SPORT CLUB CONCUSSION MANAGEMENT MODEL Cncussin awareness has increased significantly in recent years. The Natinal Cllegiate Athletic Assciatin (NCAA), Natinal Athletic Trainers Assciatin
More informationSubject: Baricitinib (Olumiant ) Tablet
09-J3000-10 Original Effective Date: 09/15/18 Reviewed: 08/08/18 Revised: 00/00/00 Subject: Baricitinib (Olumiant ) Tablet THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationORAL AND PARENTERAL METHOTREXATE RHEUMATOLOGY LOCAL SAFETY MONITORING SCHEDULE
ORAL AND PARENTERAL METHOTREXATE RHEUMATOLOGY LOCAL SAFETY MONITORING SCHEDULE This lcal safety-mnitring schedule supprts clinicians under the Lcal Enhanced Service fr High Risk Drug Mnitring (frmerly
More informationShared Care Protocol for the prescribing and monitoring of maintenance doses of azathioprine in Inflammatory Bowel Disease
Apprved by the Bedfrdshire and Lutn Jint Prescribing Cmmittee (JPC) December 2013, Review date December 2016 Bedfrdshire and Lutn Jint Prescribing Cmmittee Shared Care Prtcl fr the prescribing and mnitring
More informationGuideline for the Prescribing of Biologic Therapy in adult patients ( 16 years) with active and progressive Psoriatic Arthritis (PsA) within NHS Fife
Guideline fr the Prescribing f Bilgic Therapy in adult patients ( 16 years) with active and prgressive Psriatic Arthritis (PsA) within NHS Fife Dcument Number & Versin Versin 1.0 Date Ratified: 20/12/16
More informationNutrition Care Process Model Tutorials. Nutrition Monitoring & Evaluation: Overview & Definition. By the end of this module, the participant will:
Nutritin Care Prcess Mdel Tutrials Nutritin Care Prcess and Terminlgy Cmmittee Academy f Nutritin and Dietetics Nutritin Care Prcess Terminlgy 2015 Editin Nutritin Mnitring & Evaluatin: Overview & Definitin
More informationCognitive enhancers for the treatment of Alzheimer s disease
Cmprehensive Research Plan: Cgnitive enhancers fr the treatment f Alzheimer s disease Pharmacepidemilgy Unit February 13 th, 2015 30 Bnd Street, Trnt ON, M5B 1W8 www.dprn.ca inf@dprn.ca 2 ODPRN Drug Class
More informationΥποτροπιάζουσες Περικαρδίτιδες: Τι νεότερο; Γεώργιος Λάζαρος Επιμελητής Α Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Γ.Ν.
Υποτροπιάζουσες Περικαρδίτιδες: Τι νεότερο; Γεώργιος Λάζαρος Επιμελητής Α Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Γ.Ν. Αθηνών Recurrent pericarditis after an initial episde f pericarditis ranges
More informationObesity/Morbid Obesity/BMI
Obesity/mrbid besity/bdy mass index (adult) Obesity/Mrbid Obesity/BMI Definitins and backgrund Diagnsis cde assignment is based n the prvider s clinical judgment and crrespnding medical recrd dcumentatin
More informationSCIG: Hizentra, Gammagard Liquid, Gamunex -C, Gammaked, Hyqvia, Cuvitru (immune globulin SQ)
SCIG: Hizentra, Gammagard Liquid, Gamunex -C, Gammaked, Hyqvia, Cuvitru (immune glbulin SQ) Dcument Number: IC-0059 Last Review Date: 04/03/2018 Date f Origin: 7/20/2010 Dates Reviewed: 9/2010, 12/2010,
More information2017 CMS Web Interface
CMS Web Interface PREV-5 (NQF 2372): Breast Cancer Screening Measure Steward: NCQA Web Interface V1.0 Page 1 f 18 11/15/2016 Cntents INTRODUCTION... 3 WEB INTERFACE SAMPLING INFORMATION... 4 BENEFICIARY
More informationFDA Dietary Supplement cgmp
FDA Dietary Supplement cgmp FEBRUARY 2009 OVERVIEW Summary The Fd and Drug Administratin (FDA) has issued a final rule regarding current gd manufacturing practices (cgmp) fr dietary supplements that establishes
More information