Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Size: px
Start display at page:

Download "Medical Policy An independent licensee of the Blue Cross Blue Shield Association"

Transcription

1 Page 1 of 5 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Prime Therapeutics will review Prior Authorization requests Prior Authorization Form: Link to Drug List (Formulary): Professional Institutional Original Effective Date: May 2, 2017 Original Effective Date: May 2, 2017 Revision Date(s): May 2, 2017; November 15, 2017 Revision Date(s): May 2, 2017; November 15, 2017 Current Effective Date: November 15, 2017 Current Effective Date: November 15, 2017 State and Federal mandates and health plan member contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service. The BCBSKS Medical Policies contained herein are for informational purposes and apply only to members who have health insurance through BCBSKS or who are covered by a self-insured group plan administered by BCBSKS. Medical Policy for FEP members is subject to FEP medical policy which may differ from BCBSKS Medical Policy. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents of Blue Cross and Blue Shield of Kansas and are solely responsible for diagnosis, treatment and medical advice. If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan. DESCRIPTION The intent of the prior authorization (PA) requirement for is to encourage appropriate selection of patients for treatment according to product labeling and/or clinical studies and/or guidelines and according to dosing recommended in product labeling. Target Drugs

2 Page 2 of 5 Ingrezza (valbenazine) FDA Approved Indication and Dosage 1 Indication: is indicated for the treatment of adults with tardive dyskinesia Dosing: The initial dose for is 40 mg once daily. After one week, increase the dose to the recommended dose of 80 mg once daily. Continuation of 40 mg once daily may be considered for some patients. POLICY Initial Prior Authorization Criteria and Quantity Limits for Approval The requested agents will be approved when the following are met: 1. The patient is an adult ( 18 years old) 2. The patient has a diagnosis of tardive dyskinesia 3. ONE of the following: a. The prescriber is a specialist in the area of the patient s diagnosis (e.g., psychiatrist, neurologist) b. The prescriber has consulted with a specialist in the area of the patient s diagnosis 4. ONE of the following: a. The prescriber has reduced the dose or discontinued any medications known to cause tardive dyskinesia (i.e., dopamine receptor blocking agents) b. The prescriber has provided clinical rationale indicating that a reduced dose or discontinuation of the offending agent is not appropriate 5. The prescriber has documented the patient s baseline Abnormal Involuntary Movement Scale (AIMS) score 6. The patient does NOT have any FDA labeled contraindications to therapy with the requested agent 7. ONE of the following:

3 Page 3 of 5 a. The requested quantity (dose) is NOT greater than the program quantity b. ALL of the following: i. The requested quantity (dose) is greater than the program quantity ii. The requested quantity (dose) is less than or equal to the FDA labeled dose iii. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the Length of Approval: 2 months Renewal Evaluation This agent will be approved for renewal when the following criteria are met: 1. The patient has been previously approved for therapy with the requested agent through Prime Therapeutics PA process 2. ONE of the following: a. The prescriber is a specialist in the area of the patient s diagnosis (e.g., psychiatrist, neurologist) b. The prescriber has consulted with a specialist in the area of the patient s diagnosis 3. The patient has had an improvement from baseline in Abnormal Involuntary Movement Scale (AIMS) score 4. The patient does NOT have any FDA labeled contraindications to therapy with the requested agent 5. ONE of the following: a. The requested quantity (dose) is NOT greater than the program quantity b. ALL of the following

4 Page 4 of 5 i. The requested quantity (dose) is greater than the program quantity ii. The requested quantity (dose) is less than or equal to the FDA labeled dose iii. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the Length of Approval: 12 months Agent Contraindications None Program Quantity Limits Brand (generic) Quantity Limit 40 mg capsule 2 capsules/day RATIONALE Prolonged use of dopamine receptor blocking agents (e.g., antipsychotic drugs, metoclopramide) can cause a delayed onset of a hyperkinetic movement disorder called tardive dyskinesia (TD). Onset of TD is insidious and often occurs while on the offending drug, such as an antipsychotic. Manifestations also commonly present when there is a dose reduction of the antipsychotic, when the antipsychotic is switched to a less potent one, or when the antipsychotic is discontinued. Typical clinical symptoms can include oral, facial, and lingual dyskinesias (e.g., protruding / twisting movements of the tongue, pouting/puckering/smacking movements of the lips, bulging of the cheeks, chewing movements, retraction of the corners of the mouth). To assess the severity of TD symptoms and impact of treatment, the Abnormal Involuntary Movement Scale (AIMS) * has been used in clinical and research settings. Treatment recommendations have been developed by the American Psychiatric Association and the American Academy of Neurology. Therapy for TD has primarily focused on decreasing and then stopping the offending agent, and switching to a different antipsychotic if one is still needed. It is often not possible to stop the antipsychotic immediately because TD symptoms can worsen upon withdrawal. Though patients with TD symptoms may improve with these changes, complete resolution of symptoms is rare, and long-lasting or permanent symptoms can be seen, even if the patient is taken off antipsychotics completely. Prior to the approval of valbenazine, there was no FDA approved drug to treat TD. A randomized, double-blind, placebo-controlled trial of valbenazine (published: KINECT-33) was conducted in patients with moderate to severe TD as determined by clinical observation. The Abnormal Involuntary Movement Scale (AIMS) was the primary efficacy measure for the assessment of TD

5 Page 5 of 5 severity. The primary efficacy endpoint was the mean change from baseline in the AIMS dyskinesia total score at the end of Week 6. The change from baseline in the AIMS total dyskinesia score in the 80 mg valbenazine group was statistically significantly different from the change in the placebo group. Changes from baseline to week 6 in AIMS dyskinesia score were for the 80 mg/day group and -0.1 for the placebo group (p<0.001), corresponding to an effect size of A supportive analysis in the per-protocol population also showed a difference in favor of valbenazine at 80 mg/day for AIMS dyskinesia score reduction at week 6 (-3.7, vs for placebo; p<0.001). A validated minimal clinically important difference has not been established for change in AIMS dyskinesia score, partly because of the lack of comparability between multiple versions of the AIMS used in previous studies in TD. *The AIMS is a 12-item scale; items 1 to 7 assess the severity of involuntary movements across body regions and these items were used in this study. Each of the 7 items was scored on a 0 to 4 scale, rated as: 0=no dyskinesia; 1=low amplitude, present during some but not most of the exam; 2=low amplitude and present during most of the exam (or moderate amplitude and present during some of the exam); 3=moderate amplitude and present during most of exam; or 4=maximal amplitude and present during most of exam. The AIMS dyskinesia total score (sum of items 1 to 7) could range from 0 to 28, with a decrease in score indicating improvement. Safety 1 Valbenazine does not have any contraindications. REVISIONS Policy published in New to Market Drugs policy on Policy retroeffective to Policy published as a stand-alone policy on Effective REFERENCES 1. Ingrezza prescribing information. Neurocrine Biosciences, Inc. 04/ UpToDate. Tardive dyskinesia. Literature review current through: March Accessed April Vijayakumar D, Jankovic J. Drug-induced dyskinesia, part 2: Treatment of Tardive Dyskinesia. Drugs 2016;76: Institute for Clinical and Economic Review (ICER). Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value. Draft Background and Scope. May 8, Hauser R, Factor S, Marder S, et al. KINECT 3: A Phase 3 randomized, double-blind, placebo-controlled trial of valbenazine for tardive dyskinesia. Am J Psychiatry 2017;174:

Ingrezza (valbenazine)

Ingrezza (valbenazine) Ingrezza (valbenazine) Policy Number: 5.01.635 Last Review: 7/2018 Origination: 07/2017 Next Review: 7/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for Ingrezza

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Xermelo (telotristat) Page 1 of 5 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Xermelo (telotristat) Prime Therapeutics will review Prior Authorization requests

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Xermelo (telotristat) Page 1 of 5 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Xermelo (telotristat) Prime Therapeutics will review Prior Authorization requests

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association New to Market Drugs Page 1 of 5 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: New to Market Drugs: Including (cannabidiol) Prime Therapeutics will review Prior

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Ocaliva (obeticholic acid) Page 1 of 6 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Ocaliva (obeticholic acid) Prime Therapeutics will review Prior Authorization

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Neprilysin Inhibitor (Entresto ) Page 1 of 6 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Neprilysin Inhibitor (Entresto ) Prime Therapeutics will review Prior

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association CGRP Page 1 of 8 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: CGRP (calcitonin gene-related peptide) Prime Therapeutics will review Prior Authorization requests

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Topical Doxepin Page 1 of 5 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Topical Doxepin Prime Therapeutics will review Prior Authorization requests Prior Authorization

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Topical Doxepin Page 1 of 6 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Topical Doxepin (For Individuals Who Purchased BlueCare/KS Solutions/EPO Products) Prime

More information

Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association

Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association Ampyra (dalfampridine) Page 1 of 9 Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association Title: Ampyra (dalfampridine) Prime Therapeutics will review Prior Authorization

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Natpara (parathyroid hormone) Page 1 of 8 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Natpara (parathyroid hormone) Prime Therapeutics will review Prior Authorization

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Afrezza Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Afrezza (human insulin) Prime Therapeutics will review Prior Authorization requests Prior Authorization

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Oral Anticoagulants Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Oral Anticoagulant - Bevyxxa (betrixaban), Eliquis (apixaban), Pradaxa (dabigatran),

More information

Ingrezza. Ingrezza (valbenazine) Description

Ingrezza. Ingrezza (valbenazine) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.60.29 Subject: Ingrezza Page: 1 of 5 Last Review Date: December 8, 2017 Ingrezza Description Ingrezza

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Cystic Fibrosis Transmembrane Page 1 of 11 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prime Therapeutics

More information

Vesicular Monoamine Transporter Type 2 Inhibitors: deutetrabenazine (Austedo ), tetrabenazine (Xenazine ), valbenazine (Ingrezza )

Vesicular Monoamine Transporter Type 2 Inhibitors: deutetrabenazine (Austedo ), tetrabenazine (Xenazine ), valbenazine (Ingrezza ) Vesicular Monoamine Transporter Type 2 Inhibitors: deutetrabenazine (Austedo ), tetrabenazine (Xenazine ), valbenazine (Ingrezza ) Applies to all products administered or underwritten by Blue Cross and

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Cystic Fibrosis Transmembrane Page 1 of 13 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Prime Therapeutics

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Substrate Reduction Therapy Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Substrate Reduction Therapy! Prime Therapeutics will review Prior Authorization

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Urea Cycle Disorders Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Urea Cycle Disorders Prime Therapeutics will review Prior Authorization requests

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Strensiq (asfotase alfa) Page 1 of 5 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Strensiq (asfotase alfa) Prime Therapeutics will review Prior Authorization

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Otezla (apremilast) Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Otezla (apremilast) Prime Therapeutics will review Prior Authorization requests Prior

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association CGRP Page 1 of 13 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: CGRP (calcitonin gene-related peptide) Prime Therapeutics will review Prior Authorization requests

More information

Presented at the American Psychiatric Association Annual Meeting May 20 24, 2017 San Diego, CA.

Presented at the American Psychiatric Association Annual Meeting May 20 24, 2017 San Diego, CA. Original Presentations Key Words: amines, antipsychotic agents, double-blind method, mood disorders, psychopharmacology, psychotic disorders, schizophrenia, tardive dyskinesia, valbenazine Efficacy of

More information

Xenazine. Xenazine (tetrabenazine) Description

Xenazine. Xenazine (tetrabenazine) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Xenazine Page: 1 of 5 Last Review Date: November 30, 2018 Xenazine Description Xenazine (tetrabenazine)

More information

Prior Authorization with Quantity Limit Program Summary

Prior Authorization with Quantity Limit Program Summary Gocovri (amantadine) Prior Authorization with Quantity Limit Program Summary This prior authorization applies to Commercial, NetResults A series, SourceRx and Health Insurance Marketplace formularies.

More information

Molina Healthcare of Texas

Molina Healthcare of Texas Texas Standard Prior Authorization Form Addendum Molina Healthcare of Texas Ingrezza (Marketplace) This fax machine is located in a secure location as required by HIPAA Regulations. Complete / Review information,

More information

Austedo. Austedo (deutetrabenazine) Description

Austedo. Austedo (deutetrabenazine) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.60.15 Subject: Austedo Page: 1 of 6 Last Review Date: September 15, 2017 Austedo Description Austedo

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Opioid Immediate Release Page 1 of 13 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Opioid Immediate Release Prime Therapeutics will review Prior Authorization

More information

AUSTEDO (deutetrabenazine) oral tablet INGREZZA (valbenazine) oral capsule XENAZINE (tetrabenazine) oral tablet Tetrabenazine oral tablet

AUSTEDO (deutetrabenazine) oral tablet INGREZZA (valbenazine) oral capsule XENAZINE (tetrabenazine) oral tablet Tetrabenazine oral tablet Tetrabenazine oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage Guideline

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Oral Immunotherapy Agents Page 1 of 13 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Oral Immunotherapy Agents Prime Therapeutics will review Prior Authorization

More information

Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value

Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value Stakeholder Input Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value Draft Background and Scope May 8, 2017 This scoping document was developed with extensive

More information

Xenazine. Xenazine (tetrabenazine) Description

Xenazine. Xenazine (tetrabenazine) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.60.12 Subject: Xenazine Page: 1 of 5 Last Review Date: December 8, 2017 Xenazine Description Xenazine

More information

Addyi (flibanserin) When Policy Topic is covered Coverage of Addyi is recommended in those who meet the following criteria:

Addyi (flibanserin) When Policy Topic is covered Coverage of Addyi is recommended in those who meet the following criteria: Addyi (flibanserin) Policy Number: 5.01.605 Last Review: 10/2018 Origination: 10/2015 Next Review: 10/2019 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for Addyi when

More information

Treating Tardive Dyskinesia: Clinical Challenges and Patient Perspectives

Treating Tardive Dyskinesia: Clinical Challenges and Patient Perspectives Treating Tardive Dyskinesia: Clinical Challenges and Patient Perspectives Interim Outcomes Report (as of November 20, 2018) Supported by an educational grant from Neurocrine Biosciences Overview Activity

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Xolair (omalizumab) Page 1 of 15 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Xolair (omalizumab) Prime Therapeutics will review Prior Authorization requests.

More information

Neurocrine Biosciences, Inc. THE NEUROENDROCRINE COMPANY

Neurocrine Biosciences, Inc. THE NEUROENDROCRINE COMPANY Neurocrine Biosciences, Inc. THE NEUROENDROCRINE COMPANY Safe Harbor Statement In addition to historical facts, these slides contain forward-looking statements that involve a number of risks and uncertainties.

More information

Ingrezza. (valbenazine) New Product Slideshow

Ingrezza. (valbenazine) New Product Slideshow Ingrezza (valbenazine) New Product Slideshow Introduction Brand name: Ingrezza Generic name: Valbenazine Pharmacological class: Vesicular monoamine transporter 2 (VMAT2) inhibitor Strength and Formulation:

More information

Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value

Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value Stakeholder Input Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value Revised Background and Scope June 9, 2017 This scoping document was developed with extensive

More information

Dopamine Depleting Drugs

Dopamine Depleting Drugs Parkinson's Disease Center and Movement Disorders Clinic 7200 Cambridge Street, 9th Floor, Suite 9A Houston, Texas 77030 713-798-2273 phone www.jankovic.org Dopamine Depleting Drugs Introduction Movement

More information

CENTENE PHARMACY AND THERAPEUTICS DRUG REVIEW 1Q18 January February

CENTENE PHARMACY AND THERAPEUTICS DRUG REVIEW 1Q18 January February BRAND NAME Austedo TM GENERIC NAME Deutetrabenazine MANUFACTURER Teva Pharmaceuticals USA, Inc. DATE OF APPROVAL August 30, 2017 PRODUCT LAUNCH DATE Currently commercially available REVIEW TYPE Review

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Sensorimotor and Neurobehavioral Status Exams Page 1 of 5 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Sensorimotor and Neurobehavioral Status Exams for Optometric

More information

For Tardive Dyskinesia

For Tardive Dyskinesia A LOOK AT VMAT2 INHIBITORS DECEMBER 2017 For Tardive Dyskinesia Tardive dyskinesia (TD) is a repetitive, involuntary movement disorder caused by prolonged use of medications that block the dopamine receptor,

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: (Vraylar) Reference Number: CP.PMN.91 Effective Date: 11.16.16 Last Review Date: 02.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy

More information

US Tardive Dyskinesia Market: Size, Trends & Forecasts ( ) December 2016

US Tardive Dyskinesia Market: Size, Trends & Forecasts ( ) December 2016 US Tardive Dyskinesia Market: Size, Trends & Forecasts (2016-2025) December 2016 US Tardive Dyskinesia Market Report Scope of the Report The report entitled US Tardive Dyskinesia Market: Size, Trends &

More information

Clinical Policy: Lisdexamfetamine (Vyvanse) Reference Number: CP.PMN.121 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Lisdexamfetamine (Vyvanse) Reference Number: CP.PMN.121 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: (Vyvanse) Reference Number: CP.PMN.121 Effective Date: 02.01.09 Last Review Date: 05.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important

More information

Clinical Policy: Lisdexamfetamine (Vyvanse) Reference Number: NH.PMN.36 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Lisdexamfetamine (Vyvanse) Reference Number: NH.PMN.36 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: Lisdexamfetamine (Vyvanse) Reference Number: NH.PMN.36 Effective Date: 02.09 Last Review Date: 02.19 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Idiopathic Pulmonary Fibrosis Page 1 of 10 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Idiopathic Pulmonary Fibrosis (Esbriet /pirfenidone, Ofev /nintedanib)

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Hereditary Angioedema Page 1 of 17 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Hereditary Angioedema (Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest,

More information

Clinical Policy: Lisdexamfetamine (Vyvanse) Reference Number: CP.PMN.121 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Lisdexamfetamine (Vyvanse) Reference Number: CP.PMN.121 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: (Vyvanse) Reference Number: CP.PMN.121 Effective Date: 02.01.09 Last Review Date: 02.19 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association H.P. Acthar Gel (repository corticotropin) Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: H.P. Acthar Gel (repository corticotropin) Prime Therapeutics

More information

Neurocrine Biosciences, Inc. THE NEUROENDOCRINE COMPANY

Neurocrine Biosciences, Inc. THE NEUROENDOCRINE COMPANY Neurocrine Biosciences, Inc. THE NEUROENDOCRINE COMPANY Safe Harbor Statement In addition to historical facts, this presentation contains forward-looking statements that involve a number of risks and uncertainties.

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Surgical Treatment of Gynecomastia Page 1 of 6 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Surgical Treatment of Gynecomastia Professional Institutional Original

More information

Xenazine. Xenazine (tetrabenazine) Description

Xenazine. Xenazine (tetrabenazine) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Xenazine Page: 1 of 5 Last Review Date: June 12, 2014 Xenazine Description Xenazine (tetrabenazine)

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Implanted Peripheral Nerve Stimulator (PNS) for Pain Control Page 1 of 6 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Implanted Peripheral Nerve Stimulator (PNS)

More information

Vosevi (sofosbuvir/velpatasvir/voxilaprevir)

Vosevi (sofosbuvir/velpatasvir/voxilaprevir) Vosevi (sofosbuvir/velpatasvir/voxilaprevir) Policy Number: 5.01.646 Last Review: 10/2017 Origination: 10/2017 Next Review: 11/2018 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide

More information

Could your uncontrollable movements be tardive dyskinesia (TD)? There s a treatment with INGREZZA.

Could your uncontrollable movements be tardive dyskinesia (TD)? There s a treatment with INGREZZA. Lip smacking, eye blinking, dancing hands and fingers, hip jerking... Could your uncontrollable movements be tardive dyskinesia (TD)? There s a treatment with INGREZZA. Approved for adults with TD TD can

More information

Clinical Policy: Olanzapine Orally Disintegrating Tablet (Zyprexa Zydis) Reference Number: CP.PMN.29 Effective Date: Last Review Date: 02.

Clinical Policy: Olanzapine Orally Disintegrating Tablet (Zyprexa Zydis) Reference Number: CP.PMN.29 Effective Date: Last Review Date: 02. Clinical Policy: (Zyprexa Zydis) Reference Number: CP.PMN.29 Effective Date: 08.01.15 Last Review Date: 02.19 Line of Business: Medicaid See Important Reminder at the end of this policy for important regulatory

More information

Clinical Policy: Levomilnacipran (Fetzima) Reference Number: HIM.PA.125 Effective Date: Last Review Date: 11.18

Clinical Policy: Levomilnacipran (Fetzima) Reference Number: HIM.PA.125 Effective Date: Last Review Date: 11.18 Clinical Policy: (Fetzima) Reference Number: HIM.PA.125 Effective Date: 12.01.17 Last Review Date: 11.18 Line of Business: HIM Revision Log See Important Reminder at the end of this policy for important

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Surgical Treatment of Gynecomastia Page 1 of 6 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Surgical Treatment of Gynecomastia Professional Institutional Original

More information

Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association

Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association Implanted Peripheral Nerve Stimulator (PNS) Page 1 of 6 Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association Title: Implanted Peripheral Nerve Stimulator (PNS) for Pain

More information

Clinical Policy: Lisdexamfetamine (Vyvanse) Reference Number: CP. PPA.03. Line of Business: Medicaid

Clinical Policy: Lisdexamfetamine (Vyvanse) Reference Number: CP. PPA.03. Line of Business: Medicaid Clinical Policy: (Vyvanse) Reference Number: CP. PPA.03 Effective Date: 02/09 Last Review Date: 05/17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of this

More information

PROVIDED IN RESPONSE TO YOUR UNSOLICITED REQUEST FOR INFORMATION

PROVIDED IN RESPONSE TO YOUR UNSOLICITED REQUEST FOR INFORMATION KINECT 2 NCT01733121 Baseline Week 2 Week 4 Week 6 Valbenazine 25-75 mg Valbenazine 40 mg KINECT 3 NCT02274558 Valbenazine 80 mg a KINECT 2 and KINECT 3 were 6-week, double-blind placebo-controlled trials

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: (Austedo) Reference Number: CP.PHAR.341 Effective Date: 06.13.17 Last Review Date: 05.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy

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: (Saphris) Reference Number: CP.PMN.15 Effective Date: 12.01.14 Last Review Date: 02.18 Line of Business: Commercial, Health Insurance Marketplace, Medicaid Revision Log See Important Reminder

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association.

Medical Policy An independent licensee of the Blue Cross Blue Shield Association. Insulin Pump Page 1 of 12 Medical Policy An independent licensee of the Blue Cross Blue Shield Association. Title: Insulin Pump Professional Original Effective Date: January 1, 1999 Revision Date(s): June

More information

Clinical Policy: Clomipramine (Anafranil) Reference Number: HIM.PA.149 Effective Date: Last Review Date: 05.18

Clinical Policy: Clomipramine (Anafranil) Reference Number: HIM.PA.149 Effective Date: Last Review Date: 05.18 Clinical Policy: (Anafranil) Reference Number: HIM.PA.149 Effective Date: 03.13.18 Last Review Date: 05.18 Line of Business: HIM Revision Log See Important Reminder at the end of this policy for important

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: Omega-3-Acid Ethyl Esters (Lovaza) Reference Number: CP.PMN.52 Effective Date: 07.01.18 Last Review Date: 02.18 Line of Business: Oregon Health Plan Revision Log See Important Reminder

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Breast Reconstructive Surgery After Mastectomy Page 1 of 8 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Breast Reconstructive Surgery After Mastectomy PRE-DETERMINATION

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: (Radicava) Reference Number: CP.PHAR.343 Effective Date: 07.01.17 Last Review Date: 05.18 Line of Business: Commercial, Medicaid, HIM-Medical Benefit Coding Implications Revision Log See

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: (Rexulti) Reference Number: CP.PMN.68 Effective Date: 11.05.15 Last Review Date: 02.18 Line of Business: Commercial, Health Insurance Marketplace, Medicaid Revision Log See Important Reminder

More information

Clinical Policy: Atomoxetine (Strattera) Reference Number: CP.PST.17 Effective Date:

Clinical Policy: Atomoxetine (Strattera) Reference Number: CP.PST.17 Effective Date: Clinical Policy: (Strattera) Reference Number: CP.PST.17 Effective Date: 08.01.17 Last Review Date: 08.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Xolair (omalizumab) Page 1 of 15 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Xolair (omalizumab) Prime Therapeutics will review Prior Authorization requests.

More information

XADAGO (safinamide) oral tablet

XADAGO (safinamide) oral tablet XADAGO (safinamide) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage

More information

Takhzyro (lanadelumab-flyo)

Takhzyro (lanadelumab-flyo) Takhzyro (lanadelumab-flyo) Policy Number: 5.01.675 Last Review: 1/2019 Origination: 1/2019 Next Review: 1/2020 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will provide coverage for Takhzyro

More information

Clinical Policy: Safinamide (Xadago) Reference Number: CP.CPA.308 Effective Date: Last Review Date: Line of Business: Commercial

Clinical Policy: Safinamide (Xadago) Reference Number: CP.CPA.308 Effective Date: Last Review Date: Line of Business: Commercial Clinical Policy: Safinamide (Xadago) Reference Number: CP.CPA.308 Effective Date: 05.16.17 Last Review Date: 08.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy

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: (Invega) Reference Number: CP. PMA.10.11.19 Effective Date: 10.06.16 Last Review Date: 04.18 Line of Business: CenpaticoMedicaid Revision Log See Important Reminder at the end of this

More information

FLUOXETINE 60 MG oral tablet FLUOXETINE 90 MG oral delayed release (once weekly) capsule

FLUOXETINE 60 MG oral tablet FLUOXETINE 90 MG oral delayed release (once weekly) capsule FLUOXETINE 90 MG oral delayed release (once weekly) capsule Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Hepatitis C First Generation Agents Page 1 of 16 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: See also: Hepatitis C First Generation Agents - Through Preferred

More information

Clinical Policy: Carbidopa-Levodopa ER Capsules (Rytary) Reference Number: CP.CPA.148 Effective Date: Last Review Date: 08.

Clinical Policy: Carbidopa-Levodopa ER Capsules (Rytary) Reference Number: CP.CPA.148 Effective Date: Last Review Date: 08. Clinical Policy: (Rytary) Reference Number: CP.CPA.148 Effective Date: 11.16.16 Last Review Date: 08.18 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important

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: Reference Number: LA.PPA.12 Effective Date: 02/11 Last Review Date: 01/18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of this policy for

More information

Clinical Policy: Opioid Analgesics Reference Number: CP.PMN.97 Effective Date: Last Review Date: 02.18

Clinical Policy: Opioid Analgesics Reference Number: CP.PMN.97 Effective Date: Last Review Date: 02.18 Clinical Policy: Reference Number: CP.PMN.97 Effective Date: 02.11 Last Review Date: 02.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important regulatory

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: (Trintellix) Reference Number: CP.PMN.65 Effective Date: 05.01.15 Last Review Date: 08.18 Line of Business: HIM, Medicaid Revision Log See Important Reminder at the end of this policy

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: (Northera) Reference Number: CP.PMN.17 Effective Date: 08.01.16 Last Review Date: 11.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this policy

More information

Clinical Policy: Vilazodone (Viibryd) Reference Number: CP.PMN.145 Effective Date: Last Review Date: Line of Business: HIM, Medicaid

Clinical Policy: Vilazodone (Viibryd) Reference Number: CP.PMN.145 Effective Date: Last Review Date: Line of Business: HIM, Medicaid Clinical Policy: (Viibryd) Reference Number: CP.PMN.145 Effective Date: 08.01.12 Last Review Date: 08.18 Line of Business: HIM, Medicaid Revision Log See Important Reminder at the end of this policy for

More information

Could your uncontrollable movements be tardive dyskinesia (TD)?

Could your uncontrollable movements be tardive dyskinesia (TD)? Could your uncontrollable movements be tardive dyskinesia (TD)? For adults with TD, there's a convenient treatment with INGREZZA: One capsule, once daily. Important Information Approved Use INGREZZA (valbenazine)

More information

Clinical Policy: Levetiracetam (Spritam) Reference Number: CP.CPA.156 Effective Date: Last Review Date: 11.18

Clinical Policy: Levetiracetam (Spritam) Reference Number: CP.CPA.156 Effective Date: Last Review Date: 11.18 Clinical Policy: (Spritam) Reference Number: CP.CPA.156 Effective Date: 11.16.16 Last Review Date: 11.18 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important

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: (Tafinlar) Reference Number: CP.PHAR.239 Effective Date: 11.16.16 Last Review Date: 08.18 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the end of

More information

Vertebral Axial Decompression

Vertebral Axial Decompression Vertebral Axial Decompression Policy Number: 8.03.09 Last Review: 11/2017 Origination: 11/2005 Next Review: 11/2018 Policy Blue Cross and Blue Shield of Kansas City (Blue KC) will not provide coverage

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: Brigatinib (Alunbrig) Reference Number: CP.PHAR.342 Effective Date: 07.17.17 Last Review Date: 05.18 Line of Business: Commercial; Medicaid Revision Log See Important Reminder at the end

More information

Clinical Policy: Clozapine orally disintegrating tablet (Fazaclo) Reference Number: CP.PMN.12 Effective Date: Last Review Date: 02.

Clinical Policy: Clozapine orally disintegrating tablet (Fazaclo) Reference Number: CP.PMN.12 Effective Date: Last Review Date: 02. Clinical Policy: Clozapine orally disintegrating tablet (Fazaclo) Reference Number: CP.PMN.12 Effective Date: 08.01.15 Last Review Date: 02.18 Line of Business: Medicaid Revision Log See Important Reminder

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Hepatitis C First Generation Agents Page 1 of 18 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: See also: Hepatitis C First Generation Agents - Through Preferred

More information

Subject: Austedo (deutetrabenazine) Original Effective Date: 3/8/2018. Policy Number: MCP-307. Revision Date(s):

Subject: Austedo (deutetrabenazine) Original Effective Date: 3/8/2018. Policy Number: MCP-307. Revision Date(s): Subject: Austedo (deutetrabenazine) Original Effective Date: 3/8/2018 Policy Number: MCP-307 Revision Date(s): Review Date: 3/8/2018 MCPC Approval Date: 3/8/2018 DISCLAIMER This Molina Clinical Policy

More information

Nuplazid. Nuplazid (pimavanserin) Description

Nuplazid. Nuplazid (pimavanserin) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.60.03 Subject: Nuplazid Page: 1 of 4 Last Review Date: June 22, 2018 Nuplazid Description Nuplazid (pimavanserin)

More information

Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value

Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value Vesicular Monoamine Transporter 2 Inhibitors for Tardive Dyskinesia: Effectiveness and Value Evidence Report November 21, 2017 Prepared for Institute for Clinical and Economic Review, 2017 ICER Staff/Consultants

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: No Coverage Criteria/Off-Label Use Policy Reference Number: CP.PMN.53 Effective Date: 07.01.18 Last Review Date: 05.01.18 Line of Business: Oregon Health Plan Revision Log See Important

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: Indacaterol/Glycopyrrolate (Utibron Neohaler) Reference Number: CP.PMN.147 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan Revision Log See Important

More information

Clinical Policy: Milnacipran (Savella) Reference Number: CP.PPA.15. Line of Business: Medicaid

Clinical Policy: Milnacipran (Savella) Reference Number: CP.PPA.15. Line of Business: Medicaid Clinical Policy: (Savella) Reference Number: CP.PPA.15 Effective Date: 08/12 Last Review Date: 05/17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of this

More information