Pharmacy and Medical Guideline Updates
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1 STAT Bulletin PO Box Albany, New York August 2, 2010 Volume 8: Issue 19 To: All PCPs and Specialists Contracts Affected: All Lines of Business Pharmacy and ical Guideline Updates As a result of the annual guideline review performed by our Pharmacy & Therapeutics Committee, attached to this bulletin are Pharmacy and ical Guideline updates effective September 1, They are: New guidelines Guidelines with changes that will affect the review process Guidelines with date and/or reference changes (review process not affected) Auto-pay ICD-9 codes for medical injectable medications Injectable medication reference guide This information will be available for review and can be printed from our web site after August 1, Go to select I m a Provider > Tools and Resources > Pharmacy Services. If you do not have access to the internet, paper copies are available upon request after August 1, Please contact Provider Service at or Page 1 of A NENY 662.Pub CC 1624 A Division of HealthNow New York Inc. An Independent Licensee of the BlueCross BlueShield Association 662
2 New Guidelines Effective September 1, 2010 Prescription Drug Abbreviated Criteria Actemra Afinitor Arzerra Istodax Kalbitor Mozobil Oforta TM Samsca Xifaxan Policy Summary (see guidelines for specifics) An effort to allow timely review of medications that are new to the market and consistent review of third-tier managed classes and non-formulary medications Covered for moderate to severe rheumatoid arthritis, alone or with methotrexate, when there has been an inadequate response to a TNF-inhibitor Covered for advanced renal cell carcinoma when there has been a treatment failure with Sutent or Nexavar first Covered for chronic lymphocytic leukemia; preauthorization not required for ICD-9 codes 204.1, , , ; added to Abbreviated Criteria Policy Covered for cutaneous T-cell lymphoma after the use of at least one systemic therapy first Covered for the treatment of acute angioedema attacks if Cinryze or Berinert is not tolerated first, added to Hereditary Angioedema Policy Covered for peripheral mobilization of stem cells for autologous transplantation in patients diagnosed with Non- Hodgkin s lymphoma or multiple myeloma where criteria outlined in policy are met Coverage for Oforta TM is provided when the use of IV fludarabine is medically contraindicated Coverage of quantities over 20 tablets per 365 days require review Coverage is provided for hepatic encephalopathy and traveler s diarrhea according to prescribing guidelines Affect or, Page 2 of 5
3 Guidelines With Changes That Will Impact the Review Process Effective September 1, 2010 Prescription Drug Antiemetic Agents Avastin Erbitux Hyaluronan Injections* Policy Update (See guidelines for specifics) Removed prior step therapy requirements for children and hyperemesis gravidarum, Sancuso added to policy, quantity limits on ondansetron solution in place Policy statement added regarding Avastin in pancreatic cancer; deemed investigational and not medically necessary Covered in combination with irinotecan for EGFRexpressing metastatic colorectal cancer when patients are refractory to irinotecan-based chemotherapy alone Preferred agents are now Synvisc, Synvisc One, Euflexxa. A trial with two preferred agents will be required for coverage consideration of Hyalgan, Supartz, Orthovisc once general criteria is met Affect or Incretin Mimetics Renamed from Byetta, Victoza added to policy Intravenous Bisphosphonates Renamed from Reclast, Boniva IV added to policy, criteria changed for Reclast and created for Boniva Migraine Agents Sumavel Dosepro added to policy Proton Pump Inhibitors Remicade Tarceva Dexilant added to policy (Kapidex reference removed) Added a Black Box Warning regarding malignancy and lymphoma; pediatric indicated reference added for Crohn s disease Added indication for non-small cell lung cancer after no progression with four cycles of platinum-based first line therapy Torisel Torisel will not be covered in combination with Afinitor Tykerb Uloric Added indication for HER2 receptor positive metastatic breast cancer in certain patients Covered for gout that is refractory to allopurinol or patients who cannot take allopurinol Urinary Agents Gelnique added to policy *Important Note: Viscosupplementation (Hyaluronan Injections) Benefit Preauthorization for viscosupplementation therapy will be reviewed and approved through the Use Management Customer Advocate Unit effective September 1, A Customer Advocate Unit Preauthorization Form will be posted to the provider web site and should be used when requesting approval for the following: Preferred Agents: Synvisc, Synvisc One, Euflexxa Non-preferred Agents: Hyalgan, Orthovisc, Supartz Page 3 of 5
4 Guidelines with Date and/or Reference Changes (review process not affected) o Antifungal Agents o Anti-Influenza Therapy o Arcalyst o Celebrex o Diflucan 150mg o Fentanyl o Flector Patch o Gleevec o Herceptin o Kuvan o Multiple Sclerosis Agents o Nexavar o Noxafil o Nutritional Supplement/Enteral o Formulas o Osteoporosis Agents o Selzentry o Sprycel o Stadol o Sutent o Tasigna o Temodar o Vectibix o Zolinza o Zyvox Auto-Pay ICD-9 Codes for ical Injectable ications Effective September 1, 2010, some medical injectable medications will automatically pay when billed with the following diagnoses. ication (J code) Auto-pay ICD-9 codes Arzerra (J9999) 204.1, , , Avastin (J9035) , 154.0, 154.1, , , , , , , , , , , Rituxan (J9310) Lupron, Lupron Depot, Eligard (J1950, J9217, J9218) IVIg (J1561, J1568, J1569, J1566, J1572, J1562, J1563, J1459) 185, , , Macugen, Lucentis (J2503, J2778) , , , , Dacogen, Vidaza (J0894, J9025) 205.1, , , Botox, Myobloc, Dysport (J0585, J0586, J0587) 333.6, 333.7, , , , , , , , 334.1, 340, 341, 341.0, 341.1, 341.2, 341.8, 341.9, 342.1, , , 344.1, 344.2, 344.4, 351.8, 378, , 530.0, 564.6, 565.0, 723.5, 854, 952 Page 4 of 5
5 Injectable ication Reference Guide The following list of injectable medications require preauthorization when administered by a health care professional. Actemra * J3590 Macugen J2503 Actimmune J9216 Mozobil * J2562 Amevive J0215 Myobloc J0587 Arzerra * J9999 Nplate J2796 Avastin J9035 Octogam J1568 Berinert J0598 Orencia J0129 Boniva * J1740 Orthovisc J7324 Botox J0585 Privigen J1459 Cimzia J0718 Reclast J3488 Cinryze J0598 Remicade J1745 Dacogen J0894 Remodulin J3285 Dysport J0586 Rituxan J9310 Eligard J9217 Simponi J3590 Erbitux J9055 Soliris J1300 Euflexxa J7323 Stelara J3590 Flebogamma J1572 Supartz J7321 Gammagard J1569 Synagis Gamunex J1561 Synvisc J7325 Herceptin J9355 Synvisc One J7325 Hyalgan J7321 Torisel J9330 Istodax * J9999 Tysabri J2323 IVIg Powder J1566 Vectibix J9303 Kalbitor * J3590 Vidaza J9025 Lucentis J2778 Vivaglobin J1562 Lupron Depot J1950 Xolair J2357 Lupron J9218 *Effective September 1, 2010 Page 5 of 5
STAT Bulletin. Drug Therapy Guideline Updates. To: All Primary Care Physicians and Specialists Contracts Affected: All Lines of Business
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MEDICARE ADVANTAGE BlueShield of Northeastern New York Formulary Update BlueShield of Northeastern New York has updated its formulary (drug list) since its original publication in January. This document
Drug Therapy Guidelines
Simponi, Simponi Aria Applicable Medical Benefit x Effective: 2/13/18 Pharmacy- Formulary 1 x Next Review: 12/18 Pharmacy- Formulary 2 x Date of Origin: 7/2010 Pharmacy- Formulary 3/Exclusive x Review
SAMPLE IgE: ESR: CRP: # Joints: %BSA: Height: Weight: BMI:
Please Note: Medical Necessity Prior Authorization may be overrided for both formulary coverage and benefit design restrictions. They are issued at the full discretion of the benefit manager. PRIOR AUTHORIZATION
See Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Stivarga) Reference Number: CP.PHAR.107 Effective Date: 12.01.12 Last Review Date: 05.18 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the end of
Opdivo. Opdivo (nivolumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.53 Subsection: Antineoplastic nts Original Policy Date: January 16, 2015 Subject: Opdivo Page: 1 of
Afinitor. Afinitor and Afinitor Disperz (everolimus) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.62 Subject: Afinitor Page: 1 of 7 Last Review Date: June 22, 2017 Afinitor Description Afinitor and
Clinical Policy: Nivolumab (Opdivo) Reference Number: ERX.SPA.302 Effective Date:
Clinical Policy: (Opdivo) Reference Number: ERX.SPA.302 Effective Date: 03.01.19 Last Review Date: 02.19 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
2018 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services
2017 MDwise HIP Medical Services that Require Prior Authorization
2017 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance
J-Code Trade Name Drug Name Required Medical Information
FIDELIS CARE NEW YORK DEPARTMENT OF PHARMACY SERVICES Updated: 10/31/2017 J-Code Prior Authorizations & Required Clinical Information Medicaid, Child Health Plus, HealthierLife, Metal-Level J-Code Trade
Sutent. Sutent (sunitinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.95 Subject: Sutent Page: 1 of 5 Last Review Date: September 15, 2017 Sutent Description Sutent (sunitinib)
Pharmacy Management Drug Policy
SUBJECT: Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs POLICY NUMBER: PHARMACY-73 EFFECTIVE DATE: 01/01/2018 LAST REVIEW DATE: 06/11/2018 If the member s subscriber
MOST Operations Manual page 1 MEDICATION INVENTORY
MOST Operations Manual page 1 TABLE OF CONTENTS MEDICATION INVENTORY 1. Background and rationale... 2 2. Equipment and supplies... 2 3. Detailed measurement procedures... 2 3.1 Drug definition guidelines...
Center for Evidence-based Policy
P&T Committee Brief Targeted Immune Modulators: Comparative Drug Class Review Alison Little, MD Center for Evidence-based Policy Oregon Health & Science University 3455 SW US Veterans Hospital Road, SN-4N
As It Relates to You
Midwest June Newsletter June 12, 2018 As It Relates to You Coming Soon: New Online Resources and Training Opportunities To better partner with you, we re in the process of creating new education materials