MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 07/05/18 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:

Size: px
Start display at page:

Download "MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 07/05/18 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:"

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) , 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) 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 information

TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol) aerosol powder

TRELEGY 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 information

Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.

Non-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 information

ALPHA1-PROTEINASE INHIBITORS

ALPHA1-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 information

AIRDUO RESPICLICK (fluticasone-salmeterol) aerosol DULERA (mometasone furoate and formoterol fumarate dihydrate) aerosol

AIRDUO 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 information

reslizumab (Cinqair )

reslizumab (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 information

Select Inhaled Respiratory Agents

Select 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 information

LARTRUVO (olaratumab)

LARTRUVO (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 information

STELARA (ustekinumab)

STELARA (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 information

STRIVERDI RESPIMAT (olodaterol hcl) aerosol

STRIVERDI 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 information

PANCREATIC ISLET TRANSPLANT

PANCREATIC 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 information

ENDOBRONCHIAL ULTRASOUND FOR DIAGNOSIS AND STAGING OF LUNG CANCER

ENDOBRONCHIAL 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 information

MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 10/04/17 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:

MEDICAL 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 information

ENTYVIO (vedolizumab)

ENTYVIO (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 information

IMMUNE CELL FUNCTION ASSAY

IMMUNE 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 information

GENETIC TESTING FOR PREDICTING RISK OF NONFAMILIAL BREAST CANCER

GENETIC 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 information

GENETIC TESTING FOR TAMOXIFEN TREATMENT

GENETIC 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 information

benralizumab (Fasenra )

benralizumab (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 information

APOKYN (apomorphine hydrochloride)

APOKYN (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 information

CIMZIA (certolizumab pegol)

CIMZIA (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 information

GENETIC TESTING FOR KRAS, NRAS AND BRAF VARIANT ANALYSIS IN METASTATIC COLORECTAL CANCER

GENETIC 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 information

MOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES

MOLECULAR 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 information

Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.

Non-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 information

MYLOTARG (gemtuzumab ozogamicin)

MYLOTARG (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 information

HEMATOPOIETIC CELL TRANSPLANTATION FOR EPITHELIAL OVARIAN CARCINOMA

HEMATOPOIETIC 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 information

RADIOFREQUENCY ABLATION OF PRIMARY OR METASTATIC LIVER TUMORS

RADIOFREQUENCY 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 information

BLINCYTO (blinatumomab)

BLINCYTO (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 information

RELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE

RELISTOR (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 information

PERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES

PERJETA (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 information

PARSABIV (etelcalcetide)

PARSABIV (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 information

DRUG TESTING IN PAIN MANAGEMENT AND SUBSTANCE USE DISORDER(S) TREATMENT

DRUG 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 information

TREATMENTS FOR GAUCHER DISEASE

TREATMENTS 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 information

SOMATULINE DEPOT (lanreotide acetate)

SOMATULINE 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 information

GATTEX (teduglutide [rdna origin])

GATTEX (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 information

The Medical Letter. on Drugs and Therapeutics

The 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 information

TYSABRI FOR CROHN S DISEASE

TYSABRI 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 information

COPD Medications Coverage Summary Non-Insured Health Benefits Coverage SABA Bricanyl turbuhaler Yes Yes

COPD 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 information

TYMLOS (abaloparatide)

TYMLOS (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 information

ORAL IMPLANT PROCEDURES

ORAL 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 information

RADIOFREQUENCY ABLATION OF MISCELLANEOUS SOLID TUMORS EXCLUDING LIVER TUMORS

RADIOFREQUENCY 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 information

INTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION

INTRAPERITONEAL 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 information

Drug Class Monograph

Drug 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 information

COPD 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 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 information

INTRAVITREAL IMPLANTS

INTRAVITREAL 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 information

VYXEOS (daunorubicin and cytarabine)

VYXEOS (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 information

BONIVA (ibandronate sodium)

BONIVA (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 information

PROTEOMIC TESTING FOR SYSTEMIC THERAPY IN NON-SMALL-CELL LUNG CANCER

PROTEOMIC 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 information

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 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 information

CONTINUOUS OR INTERMITTENT GLUCOSE MONITORING IN INTERSTITIAL FLUID

CONTINUOUS 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 information

FECAL ANALYSIS IN THE DIAGNOSIS OF INTESTINAL DYSBIOSIS

FECAL 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 information

BRINEURA (cerliponase alfa)

BRINEURA (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 information

A Visual Approach to Simplifying Respiratory Drug Regimens

A 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 information

Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.

Non-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 information

See Important Reminder at the end of this policy for important regulatory and legal information.

See 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 information

Clinical Policy: Roflumilast (Daliresp) Reference Number: CP.PMN.46 Effective Date: Last Review Date: 08.18

Clinical 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 information

NEGATIVE PRESSURE WOUND THERAPY

NEGATIVE 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 information

MULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER

MULTIMARKER 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 information

NOVEL BIOMARKERS IN RISK ASSESSMENT AND MANAGEMENT OF CARDIOVASCULAR DISEASE

NOVEL 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 information

QUANTITY LIMIT CRITERIA. BROVANA (arformoterol tartrate) SEREVENT DISKUS (salmeterol) STRIVERDI RESPIMAT (olodaterol)

QUANTITY 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 information

COSENTYX (secukinumab)

COSENTYX (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 information

See Important Reminder at the end of this policy for important regulatory and legal information.

See 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 information

ACTEMRA (tocilizumab)

ACTEMRA (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 information

GENETIC TESTING FOR HEREDITARY HEARING LOSS

GENETIC 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 information

Ferris 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 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 information

12/18/2017. Disclosures. Asthma Management Updates: A Focus on Long-acting Muscarinic Antagonists and Intermittent Inhaled Corticosteroid Dosing

12/18/2017. 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 information

NUTRIENT OR NUTRITIONAL PANEL TESTING

NUTRIENT 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 information

DUPIXENT (dupilumab) subcutaneous injection

DUPIXENT (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 information

INTRACAVITARY BALLOON BRACHYTHERAPY FOR MALIGNANT AND METASTATIC BRAIN TUMORS

INTRACAVITARY 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 information

CARDIOVASCULAR RISK PANELS

CARDIOVASCULAR 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 information

OPTICAL COHERENCE TOMOGRAPHY (OCT) OF THE MIDDLE EAR

OPTICAL 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 information

GENETIC TESTING FOR MARFAN SYNDROME, THORACIC AORTIC ANEURYSMS AND DISSECTIONS AND RELATED DISORDERS

GENETIC 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 information

MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 11/14/17 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:

MEDICAL 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 information

Drug Effectiveness Review Project Summary Report

Drug 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 information

HEMATOPOIETIC CELL TRANSPLANTATION FOR PRIMARY AMYLOIDOSIS

HEMATOPOIETIC 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 information

H.P. ACTHAR GEL (repository corticotropin injection)

H.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 information

A Visual Approach to Simplifying Respiratory Drug Regimens

A 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 information

Clinical Policy: Dupilumab (Dupixent) Reference Number: ERX.SPA.49 Effective Date:

Clinical 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 information

A Visual Approach to Simplifying Respiratory Drug Regimens

A 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 information

Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document.

Non-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 information

DEEP BRAIN STIMULATION

DEEP 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 information

DERMATOLOGIC APPLICATIONS OF PHOTODYNAMIC THERAPY

DERMATOLOGIC 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 information

Cinqair (reslizumab injection for intravenous use)

Cinqair (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 information

Up 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 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 information

BALLOON OSTIAL DILATION FOR TREATMENT OF CHRONIC SINUSITIS

BALLOON 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 information

GENETIC TESTING FOR FANCONI ANEMIA

GENETIC 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 information

BIVENTRICULAR PACEMAKER (CARDIAC RESYNCHRONIZATION THERAPY) FOR THE TREATMENT OF HEART FAILURE

BIVENTRICULAR 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 information

PERCUTANEOUS BALLOON KYPHOPLASTY, RADIOFREQUENCY KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION

PERCUTANEOUS 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 information

Asthma/COPD Update with Inhaler Workshop

Asthma/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 information

GENETIC TESTING FOR FLT3, NPM1 AND CEBPA VARIANTS IN CYTOGENETICALLY NORMAL ACUTE MYELOID LEUKEMIA

GENETIC 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 information

INTERSPINOUS FIXATION (FUSION) DEVICES

INTERSPINOUS 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 information

GENETIC TESTING FOR NEUROFIBROMATOSIS

GENETIC 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 information

Clinical Policy: Mepolizumab (Nucala) Reference Number: ERX.SPA.214 Effective Date:

Clinical 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 information

MEDICATION 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: 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 information

REVISED RESPIRATORY MEDICATION USE QUESTIONNAIRE

REVISED 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 information

MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 03/07/18 SECTION: DRUGS LAST REVIEW DATE: 02/19/19 LAST CRITERIA REVISION DATE: ARCHIVE DATE:

MEDICAL 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 information

TRANSMYOCARDIAL REVASCULARIZATION

TRANSMYOCARDIAL 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 information

Nucala (mepolizumab injection for subcutaneous use)

Nucala (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 information

GENE EXPRESSION PROFILING AND PROTEIN BIOMARKERS FOR PROSTATE CANCER MANAGEMENT

GENE 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 information

MDI Bonanza. Dwayne Griffin, DO

MDI 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 information

MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 12/19/17 SECTION: MEDICINE LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:

MEDICAL 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