Premera Blue Cross Medicare Advantage Plans Pharmacy Policy Updates
|
|
- Emory Webster
- 6 years ago
- Views:
Transcription
1 Premera Blue Cross Medicare Advantage Plans Pharmacy Policy Updates Most Part D-eligible drugs and drug policies are not effective and administered until Centers for Medicare and Medicaid Services approval is obtained. Please refer to the most current approved formulary document at premera.com/medicare-advantage/pharmacy-services/. Pharmacy policies are updated and available on the secure provider Medicare Advantage website at premera.com/wa/provider/medicare-advantage/; simply click on the Secure Tools and Resourcesbutton in the right column. You can find the Premera Medicare Advantage (MA) Formulary (List of Covered Drugs) at premera.com/medicare-advantage/pharmacy-services/. You can also check the Premera MA Formulary using Epocrates.com: To download the formulary from epocrates.com onto your tablet or smartphone, log in to your Epocrates account, and select Edit Formularies Select Washington and Medicare Part D MA. Add Premera Medicare Advantage to Formularies on My Device and select Done Premera Medicare Advantage plans have a different formulary than non Medicare Advantage plans. There may also be differences in prior authorization criteria for Premera Medicare Advantage members and Premera members on non Medicare Advantage plans. If you have questions on specific criteria, formulary alternatives, or prior authorization/exception processes, please contact Pharmacy Services at Class Reviews Pharmacy & Therapeutics Effective April 1, 2016 (Unless noted otherwise below) Effective dates are pending CMS approval Actinic Keratosis Treatment The following medications were reviewed: imiquimod 5% (Aldara ), fluorouracil 2%, 5% (Efudex ), diclofenac 3% (Solaraze ), fluorouracil 0.5% (Carac ), imiquimod 2.5%, 3.75% (Zyclara ), and ingenol (Picato ). More than 85% of claims (between July 1 and Dec. 31, 2015) were for the generic imiquimod 5% and fluorouracil 2%, 5% products, and the cost per member per treatment was less than $300. Page 1 An Independent Licensee of the Blue Cross Blue Shield Association ( )
2 Cost of other products was significantly higher ($700 $3,300 per member per treatment). Although these represented a minority of claims, there is little to no utilization management of these products currently. Given the relatively similar efficacy, we recommend that this class of medications be managed through a prior authorization process requiring trial and failure of the generic topical medications. We recommend that the tier status of fluorouracil 0.5% (Carac ), be changed to non-preferred brand for Medicare in Generic fluorouracil 2%, 5%, and imiquimod 5%: No changes (formulary, non-preferred generic tier when applicable) Diclofenac 3% (Solaraze ), Imiquimod 2.5%, 3.75% (Zyclara ): Update prior authorization criteria; no changes to formulary status: non-formulary Fluorouracil 0.5% (Carac ), ingenol (Picato ): Formulary, Tier 4 (non-preferred brand), prior authorization, to be implemented jan. 1, 2017 New Drugs and Combinations Fillgrastim-sndz (Zarzio ) subcutaneous injection Reduce the duration of neutropenia and neutropenia-related clinical sequelae e.g. febrile neutropenia, in patients with non-myeloid malignancies undergoing myeloablative chemotherapy followed by bone marrow transplantation Reduce the time to neutrophil recovery and the duration of fever, following induction or consolidation chemotherapy treatment of patients with acute myeloid leukemia Mobilize autologous hematopoietic progenitor cells into the peripheral blood for collection by leukapheresis Reduce the incidence and duration of sequelae of severe neutropenia (e.g. fever infections oropharyngeal ulcers) in symptomatic patients with congenital neutropenia cyclic neutropenia or idiopathic neutropenia Cobimetinib (Cotellic ) tablet Indication: Malignant melanoma, Unresectable or metastatic with a BRAF V600E or V600K mutation, in combination with vemurafenib Formulary alternatives: dabrafenib (PA), trametinib (PA), vemurafenib (PA), Formulary, tier 6 (specialty), prior authorization, quantity limit of 63 per 28 days Sulfur hexafluoride microsphere (Lumason ) vial Indication: Suboptimal echocardiograms to opacify the left ventricular chamber and to improve the delineation of the left ventricular endocardial border. Part B benefit Ferric pyrophosphate citrate (Triferic ) injection Indication: Ferric pyrophosphate citrate is indicated for the replacement of iron to maintain hemoglobin in adult patients with hemodialysis-dependent chronic kidney disease (HDD-CKD). Part B benefit Irinotecan Liposomal (Onivyde ) vial Indication: A topoisomerase inhibitor indicated, in combination with fluorouracil and leucovorin, for the treatment of patients with metastatic adenocarcinoma of the pancreas after disease progression following gemcitabine-based therapy.
3 Talimogene laherparepvec (Imlygic ) suspension for injection Indication: A genetically modified oncolytic viral therapy indicated for the local treatment of unresectable cutaneous, subcutaneous, and nodal lesions in patients with melanoma recurrent after initial surgery. Trabectedin (Yondelis ) vial Indication: For the treatment of patients with unresectable or metastatic liposarcoma or leiomyosarcoma who received a prior anthracycline-containing regimen. Tagrisso (Osimertinib Mesylate) oral tablets Indication: For the treatment of patients with metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive non-small cell lung cancer (NSCLC), as detected by an FDA-approved test, who have progressed on or after EGFR tyrosine kinase inhibitor (TKI) therapy. The indication is approved under accelerated approval based on tumor response rate and duration of response. Continued approval may be contingent upon verification and description of clinical benefit in confirmatory trials. Formulary, tier 6 (specialty), prior authorization Daratumumab (Darzalex ) vial Indication: Treatment of patients with multiple myeloma who have received at least three prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent or who are doublerefractory to a PI and an immunomodulatory agent. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials. Ixazomib Citrate (Ninlaro ) capsule Indication: Indicated in combination with lenalidomide and dexamethasone for the treatment of patients with multiple myeloma who have received at least one prior therapy. Formulary, tier 6 (specialty), prior authorization Alectinib Hydrochloride (Alecensa ) capsule Indication: A kinase inhibitor indicated for the treatment of patients with anaplastic lymphoma kinase (ALK)-positive, metastatic non-small cell lung cancer (NSCLC) who have progressed on or are intolerant to crizotinib. This indication is approved under accelerated approval based on tumor response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials. Formulary alternative: Zykadia (ceritinib) Formulary, tier 6 (specialty), prior authorization New Strengths and Formulations Gefitinib (Iressa ) tablet Indication: A tyrosine kinase inhibitor indicated for the first-line treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations as detected by and FDA-approved test.
4 Limitation of Use: Safety and efficacy of Iressa have not been established in patients whose tumors have EGFR mutations other than exon 19 deletions or exon 21 (L858R) substitution mutations. Formulary, tier 6 (specialty), prior authorization, QL (30/30) Sumatriptan succinate (Zecuity ) patch Indication: A serotonin (5HT) 1b/1d receptor agonist (triptan) in an iontophoretic transdermal system, indicated for the acute treatment of migraine with or without aura in adults. Formulary alternatives: sumatriptan nasal spray, sumatriptan subcutaneous injection, sumatriptan tablets, rizatriptan tablets and orally disintegrating tablets, zolmitriptan nasal spray (formulary for commercial members), zolmitriptan tablets and orally disintegrating tablets Non-formulary Dichlorphenamide (Keveyis ) tablet Indication: The treatment of primary hyperkalemic periodic paralysis, primary hypokalemic periodic paralysis, and related variants. Non-formulary Aspirin (Durlaza ER) capsule Indication: A nonsteroidal anti-inflammatory drug indicated to reduce the risk of death and myocardial infarction (MI) in patients with chronic coronary artery disease, such as patients with a history of MI or unstable angina pectoris or with chronic stable angina and to reduce the risk of death and recurrent stroke in patients who have had an ischemic stroke or transient ischemic attack. Formulary Alternatives: Plavix, Brilinta OTC Alternatives: aspirin, enteric-coated aspirin Non-formulary New Indications Ambrisentan (Letairis ) Expanded FDA-approved indication: Letairis is an endothelin receptor antagonist indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1): To improve exercise ability and delay clinical worsening. In combination with tadalafil to reduce the risks of disease progression and hospitalization for worsening PAH, and to improve exercise ability. Studies establishing effectiveness included trials predominantly in patients with WHO Functional Class II III symptoms and etiologies of idiopathic or heritable PAH (60%) or PAH associated with connective tissue diseases (34%). Decision: Update policy with new indication Simprevir (Olysio ) Expanded FDA-approved indication: Olysiois a hepatitis C virus (HCV) NS3/4A protease inhibitor indicated for the treatment of chronic hepatitis C (CHC) genotype 1 or 4 infection as a component of a combination antiviral treatment regimen. Decision: Policies were updated with new indication. Nivolumab (Opdivo ) Expanded FDA-approved indication: Opdivo is a programmed death receptor-1 (PD-1) blocking antibody indicated for the treatment of: Unresectable or metastatic melanoma:
5 As a single agent in patients with disease progression following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor. In combination with ipilimumab in patients with BRAF V600 wild-type melanoma. These indications are approved under accelerated approval based on tumor response rate and durability of response. Continued approval for these indications may be contingent upon verification and description of clinical benefit in the confirmatory trials. Metastatic non-small cell lung cancer in patients with progression on or after platinum-based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving OPDIVO Decision: Update policy with new indication Ledipasvir/sofosbuvir (Harvoni ) Expanded FDA-approved indication: Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor, and is indicated for the treatment of chronic hepatitis C virus (HCV) genotype 1, 4, 5 or 6 infection. Decision: Policies were updated with new indication. Pegfilgrastim (Neulasta ) Expanded FDA-approved indication: Neulasta is a leukocyte growth factor indicated to: Decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. Increase survival in patients acutely exposed to myelosuppressive doses of radiation (Hematopoietic Subsyndrome of Acute Radiation Syndrome). Decision: No currently active policy, therefore, no action is needed. Rosuvastatin (Crestor ) Expanded FDA-approved indication: CRESTOR is an HMG Co-A reductase inhibitor indicated for: Patients with primary hyperlipidemia and mixed dyslipidemia as an adjunct to diet to reduce elevated total-c, LDL-C, apob, nonhdl-c, and TG levels and to increase HDL-C Pediatric patients 8 to 17 years of age with heterozygous familial hypercholesterolemia (hefh) to reduce elevated total-c, LDL-C and apob after failing an adequate trial of diet therapy Patients with hypertriglyceridemia as an adjunct to diet Patients with primary dysbetalipoproteinemia (Type III hyperlipoproteinemia) as an adjunct to diet Patients with homozygous familial hypercholesterolemia (hofh) to reduce LDL-C, total-c, and apob Slowing the progression of atherosclerosis as part of a treatment strategy to lower total-c and LDL-C as an adjunct to diet Risk reduction of MI, stroke, and arterial revascularization procedures in patients without clinically evident CHD, but with multiple risk factors Decision: No currently active policy, therefore, no updates are needed. Ibuprofen (Caldolor ) Expanded FDA-approved indication: Caldolor is a non-steroidal anti-inflammatory drug indicated in adults and pediatric patients six months and older for the: Management of mild to moderate pain and the management of moderate to severe pain as an adjunct to opioid analgesics
6 Reduction of fever Decision: No currently active policy, therefore no updates are needed. Dabigatran (Pradaxa ) Expanded FDA-approved indication: Pradaxa is a direct thrombin inhibitor indicated: To reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation For the treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients who have been treated with a parenteral anticoagulant for 5-10 days To reduce the risk of recurrence of DVT and PE in patients who have been previously treated Pradaxa 110 mg capsules: For the prophylaxis of DVT and PE in patients who have undergone hip replacement surgery Decision: No currently active policy, therefore no action is needed. Drug Safety Monitoring Drug Name Change Summary Dutasteride (Avodart ) capsule Add to formulary, non-preferred generic (tier 2) Praluent (alirocumab) Add to formulary, specialty tier with prior authorization Repatha (evolucumab) Add to formulary, specialty tier with prior authorization Clinical Policy Changes Policy Name PCSK9 Bosulif Arranon Faslodex Folotyn Herceptin Hycamtin Ixempra Xalkori Change Summary Both PCSK9 agents are being added to the formulary to capture savings in costpositioning contracts. Criteria were updated to include more practical diagnoses parameters for familial hypercholeterolemia. Removed "Other Criteria" from policy. Cancer Network (NCCN). Added reauthorization criteria requiring documented response to therapy. "Other criteria" removed and requests would be reviewed based on FDA indication and the chemotherapy operational policy as is already stated in the policy. Duration of approval changed from "3 months up to 6 months" to 6 months. More recent guidelines were referenced. "Other Criteria" removed as these requests would be reviewed based on NCCN recommendations, per operational policy. Duration of approval changed from "up to 6 months" to 6 months. Position statement updated to include a reference to NCCN Compendium recommendations. Cancer Network (NCCN). Added reauthorization criteria requiring documented response to therapy. "Other Criteria" removed as these requests would be reviewed based on NCCN recommendations, per operational policy. Duration of approval changed from 3 months to 6 months. Cancer Network (NCCN). Removed "Other Criteria" from this policy.
7 Criteria for immune thrombocytopenia (ITP) and arteritis were added as requests for these off-label uses have become more frequent. This criteria will apply only Rituxan to commercial, Medicaid, and Health Insurance Marketplace lines of business. Criteria will be submitted to CMS and will be effective once approved. Pomalyst Cancer Network (NCCN). Submit to CMS. Yervoy Removed "Other Criteria" from this policy. Gilotrif Cancer Network (NCCN). Submit to CMS. "Other criteria" removed and requests would be reviewed based on FDA indication and the chemotherapy operational policy as is already stated in the Zydelig policy. Duration of approval changed from "3 months up to 6 months" to 6 months. Submit to CMS. Abraxane Prior Authorization policy reactivated New FDA approved indications added: Opdivo 1) in combination with ipilumumab with BRAF V600 wild-type melanoma 2) renal cell carcinoma The following policies was retired: Taxol First Generics to Market Drug/Policy Name Action Taken Tobramycin (Kitabis ) Pak Line extension. Not a true generic, will process as brand non-formulary Nevirapine ER (Viramune XR ) Line extension formulary, non-preferred generic (tier 2) tablet Molindone HCL (Moban ) Line extension non-formulary tablet Repaglinide-metformin Line extension non-formulary for all lines of business (Prandimet ) tablet Linezolid (Zyvox ) suspension Line extension formulary, specialty (tier 6), pending CMS approval Dutasteride-tamsulosin (Jalyn ) Line extension non-formulary capsule Olopatadine (Patanol ) drops Add to formulary, effective April 1 Linezolid (Zyvox ) tablets Now meets generic definition, will process as generic formulary, specialty (tier 6)
Keytruda. Keytruda (pembrolizumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.50 Subject: Keytruda Page: 1 of 6 Last Review Date: September 15, 2017 Keytruda Description Keytruda
More informationKeytruda. Keytruda (pembrolizumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.50 Subject: Keytruda Page: 1 of 5 Last Review Date: June 24, 2016 Keytruda Description Keytruda (pembrolizumab)
More informationTarceva. Tarceva (erlotinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.82 Subject: Tarceva Page: 1 of 5 Last Review Date: June 22, 2018 Tarceva Description Tarceva (erlotinib)
More informationKeytruda. Keytruda (pembrolizumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.50 Subject: Keytruda Page: 1 of 7 Last Review Date: December 8, 2017 Keytruda Description Keytruda
More informationClinical Policy: Nivolumab (Opdivo) Reference Number: CP.PHAR.121 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Opdivo) Reference Number: CP.PHAR.121 Effective Date: 07.15 Last Review Date: 01.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important
More informationManufacturing and Marketing permission issued from SND Division from to
Manufacturing and Marketing permission issued from SND Division from 01.01.2017 to 17.07.2017. S.No. Drug Name Indication Date of Approval 1 Sofosbuvir 400 film coated Tablet In combination with other
More informationGENETIC TESTING FOR TARGETED THERAPY FOR NON-SMALL CELL LUNG CANCER (NSCLC)
CANCER (NSCLC) 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 informationCorporate Medical Policy
Corporate Medical Policy Molecular Analysis for Targeted Therapy for Non-Small Cell Lung File Name: Origination: Last CAP Review: Next CAP Review: Last Review: molecular_analysis_for_targeted_therapy_for_non_small_cell_lung_cancer
More informationMekinist. Mekinist (trametinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.38 Subject: Mekinist Page: 1 of 6 Last Review Date: June 22, 2017 Mekinist Description Mekinist (trametinib)
More informationPRECISION CANCER MEDICINE DR. VANESSA DICKEY TORRANCE MEMORIAL PHYSICIAN NETWORK CANCER CARE ASSOCIATES
PRECISION CANCER MEDICINE DR. VANESSA DICKEY TORRANCE MEMORIAL PHYSICIAN NETWORK CANCER CARE ASSOCIATES REAL PATIENT; ANN (ALIAS) 63 year old woman who smoked for 25 years, quit 15 years ago. Complained
More informationDrug Class Prior Authorization Criteria PCSK9 Inhibitors
Drug Class Prior Authorization Criteria PCSK9 Inhibitors Line of Business: Medicaid P & T Approval Date: February 21, 2018 Effective Date: April 1, 2018 This policy has been developed through review of
More informationGilotrif. Gilotrif (afatinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.39 Subject: Gilotrif Page: 1 of 6 Last Review Date: March 16, 2018 Gilotrif Description Gilotrif (afatinib)
More informationOpdivo. 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
More informationClinical Policy: Pembrolizumab (Keytruda) Reference Number: CP.PHAR.322
Clinical Policy: (Keytruda) Reference Number: CP.PHAR.322 Effective Date: 03/17 Last Review Date: 03/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More informationClinical Policy: Nivolumab (Opdivo) Reference Number: CP.PHAR.121
Clinical Policy: (Opdivo) Reference Number: CP.PHAR.121 Effective Date: 07/15 Last Review Date: 04/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More information2. Treatment of patients with metastatic, squamous NSCLC progressing after platinumbased
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.39 Subject: Gilotrif Page: 1 of 5 Last Review Date: September 15, 2017 Gilotrif Description Gilotrif
More informationGranix. Granix (tbo-filgrastim) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.10.16 Section: Prescription Drugs Effective Date: April 1, 2014 Subject: Granix 1 of 7 Last Review Date:
More informationLeukine. Leukine (sargramostim) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Leukine Page: 1 of 6 Last Review Date: November 30, 2018 Leukine Description Leukine (sargramostim)
More informationGranix. Granix (tbo-filgrastim) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.10.16 Subject: Granix 1 of 7 Last Review Date: September 18, 2015 Granix Description Granix (tbo-filgrastim)
More information29 August 2016 Page 1 of 7. How does the NHS board decide which new medicines to make available for patients?
NHS Greater Glasgow and Clyde: New Medicines Decisions In Scotland, a newly licensed medicine is routinely available for use in an NHS board only after it has been: accepted for use in the NHSScotland
More information2. Is therapy prescribed by, or in consultation with, a hematologist and/or oncologist?
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Colony Stimulating Factors (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Statin Therapy Page 1 of 10 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Statin Therapy Prime Therapeutics will review Prior Authorization requests. Prior Authorization
More informationGranix. Granix (tbo-filgrastim) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.85.16 Subject: Granix 1 of 7 Last Review Date: December 2, 2016 Granix Description Granix (tbo-filgrastim)
More informationClinical 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
More informationClinical Policy: Atezolizumab (Tecentriq) Reference Number: CP.PHAR.235 Effective Date: 06/16 Last Review Date: 05/17
Clinical Policy: (Tecentriq) Reference Number: CP.PHAR.235 Effective Date: 06/16 Last Review Date: 05/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Keytruda) Reference Number: CP.PHAR.322 Effective Date: 03.01.17 Last Review Date: 11.18 Line of Business: Commercial, Medicaid, HIM-Medical Benefit Revision Log See Important Reminder
More informationOpdivo. 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 Agents Original Policy Date: January 16, 2015 Subject: Opdivo Page:
More informationCommercial Formulary and Utilization Management Program Updates for January 2017 Producer Communication #782 Issued November 10, 2016
Commercial and Utilization Management Program Updates for January 2017 Producer Communication #782 Issued November 10, 2016 Message The Capital BlueCross Pharmacy & Therapeutics (P&T) Committee, consisting
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization MERC CARE (MEDICAID) Colony Stimulating Factors (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationProprotein Convertase Subtilisin/Kexin type 9(PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary
Proprotein Convertase Subtilisin/Kexin type 9(PCSK9) Inhibitors Prior Authorization with Quantity Limit Program Summary Proprotein Convertase Subtilisin/Kexin type 9(PCSK9) Inhibitors Prior Authorization
More informationTagrisso. Tagrisso (osimertinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.69 Subject: Tagrisso Page: 1 of 5 Last Review Date: September 15, 2016 Tagrisso Description Tagrisso
More informationTafinlar. Tafinlar (dabrafenib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.37 Subject: Tafinlar Page: 1 of 8 Last Review Date: September 20, 2018 Tafinlar Description Tafinlar
More informationKeytruda (pembrolizumab)
Keytruda (pembrolizumab) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date: 10/01/2015 Current Effective Date: 07/24/2017TBD03/01/2018 POLICY A. INDICATIONS The
More informationCommon Repatha Documentation Requirements for Patients With Primary Hyperlipidemia and Established CVD 1,2
Established CVD Common Repatha Documentation Requirements for Patients With Primary Hyperlipidemia and Established CVD 1,2 Primary and Secondary Diagnosis Codes Primary Diagnosis: Primary hyperlipidemia
More informationDaklinza Sovaldi. Daklinza (daclatasvir) and Sovaldi (sofosbuvir) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Daklinza Sovaldi Page: 1 of 4 Last Review Date: September 18, 2015 Daklinza Sovaldi Description
More informationCircle Yes or Y N. [Note: requests without this information will not be accepted.] [If no, then no further questions.
10/01/2016 Prior Authorization Aetna Better Health of West Virginia COLO STIMULATIG FACTORS (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationMedical 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 information2. Treatment of patients with metastatic, squamous NSCLC progressing after platinumbased
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.39 Subject: Gilotrif Page: 1 of 5 Last Review Date: June 24, 2016 Gilotrif Description Gilotrif (afatinib)
More informationRequest for Prior Authorization for PCSK9 inhibitor therapy Website Form Submit request via: Fax
Request for Prior Authorization for PCSK9 inhibitor therapy Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 PCSK9 is a protein that reduces the hepatic removal of low-density
More informationLeukine. Leukine (sargramostim) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.85.08 Subject: Leukine Page: 1 of 5 Last Review Date: September 15, 2017 Leukine Description Leukine
More informationCircle Yes or No Y N. (Note: requests without this information will not be accepted.) [If no, then no further questions.]
04/25/2016 Prior Authorization AETA BETTER HEALTH OF LA MEDICAID Colony Stimulating Factors (LA88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationKeytruda. Keytruda (pembrolizumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.50 Subject: Keytruda Page: 1 of 9 Last Review Date: September 20, 2018 Keytruda Description Keytruda
More informationClinical Therapeutic Intelligence Report: 2015 Year in Review
Clinical Therapeutic Intelligence Report: 2015 Year in Review This issue highlights the many ground-breaking therapies approved by the U.S. Food and Drug Administration over the course of 2015. Highlights
More informationLimitations of Use: Imlygic has not been shown to improve overall survival or have an effect on visceral metastases (1).
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.66 Subject: Imlygic Page: 1 of 5 Last Review Date: June 22, 2017 Imlygic Description Imlygic (talimogene
More informationRepatha. Repatha (evolocumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.16.08 Subject: Repatha Page: 1 of 8 Last Review Date: September 18, 2015 Repatha Description Repatha
More informationDaklinza Sovaldi. Daklinza (daclatasvir) and Sovaldi (sofosbuvir) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Daklinza Sovaldi Page: 1 of 7 Last Review Date: June 24, 2016 Daklinza Sovaldi Description Daklinza
More informationPCSK9 Agents Drug Class Prior Authorization Protocol
PCSK9 Agents Drug Class Prior Authorization Protocol Line of Business: Medicaid P & T Approval Date: February 21, 2018 Effective Date: April 1, 2018 This policy has been developed through review of medical
More informationPharmacy and Therapeutics (P&T) Committee Meeting February 16, :00 PM 8:00 PM MINUTES
P&T Committee Members Matthew Flynn, MD Randy Grigg, MD Kenneth Kohagen, MD David Konanc, MD Sheila Marshall, DO Jennifer Smith, PharmD Michael Spiritos, MD State Health Plan (SHP) Staff David Boerner,
More information2017 UnitedHealthcare Services, Inc.
UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2017 P 1146-7 Program Prior Authorization/Notification Medication Harvoni (ledipasvir/sofosbuvir) P&T Approval Date 10/2014, 2/2015,
More informationDrug Prior Authorization Guideline PCSK9 Inhibitors -
Drug Prior Authorization Guideline PCSK9 Inhibitors - REPATHA (evolocumab) PRALUENT (alirocumab) PA9911 Covered Service: Yes when meets criteria below Prior Authorization Required: Yes-as shown below Additional
More informationNew Cancer Drug Update 2015/2016. Teresa Knoop, MSN, RN, AOCN Vanderbilt-Ingram Cancer Center Nashville, TN
New Cancer Drug Update 2015/2016 Teresa Knoop, MSN, RN, AOCN Vanderbilt-Ingram Cancer Center Nashville, TN Disclosures No conflicts to disclose Objectives Identify new drugs that were FDA approved for
More informationRepatha. Repatha (evolocumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.40.08 Subject: Repatha Page: 1 of 8 Last Review Date: December 2, 2016 Repatha Description Repatha (evolocumab)
More informationClinical Policy: Sargramostim (Leukine) Reference Number: CP.PHAR.295
Clinical Policy: (Leukine) Reference Number: CP.PHAR.295 Effective Date: 12/16 Last Review Date: 10/16 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More informationSee 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 informationREPATHA (PCSK9 INHIBITORS)
REPATHA (PCSK9 INHIBITS) Indications: PCSK9 Inhibitors are indicated for treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease as
More informationKeytruda. Keytruda (pembrolizumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.50 Subject: Keytruda Page: 1 of 9 Last Review Date: November 30, 2018 Keytruda Description Keytruda
More informationCyramza (ramucirumab)
Cyramza (ramucirumab) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date: 10/01/2015 Current Effective Date: 03/01/2017TBD03/01/2018 POLICY A. INDICATIONS The indications
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Erbitux) Reference Number: CP.PHAR.317 Effective Date: 02.01.17 Last Review Date: 11.18 Line of Business: Commercial, HIM, Medicaid Coding Implications Revision Log See Important Reminder
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Pembrolizumab (Keytruda) Reference Number: CP.PHAR.322 Effective Date: 07.01.18 Last Review Date: 11.17 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Reference Number: CP.HNMC.05 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important Reminder at the end of this policy for important
More informationTARGETED THERAPY FOR LUNG CANCER. Patient and Caregiver Guide
TARGETED THERAPY FOR LUNG CANCER Patient and Caregiver Guide TARGETED THERAPY FOR LUNG CANCER Patient and Caregiver Guide TABLE OF CONTENTS Why Targeted Therapy?...2 Lung Cancer Basics...2 Changes in
More informationTafinlar. Tafinlar (dabrafenib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.04.37 Subject: Tafinlar Page: 1 of 6 Last Review Date: June 19, 2015 Tafinlar Description Tafinlar (dabrafenib)
More informationPantoprazole icd 10 code
Pantoprazole icd 10 code in persons with recurrent or metastatic non-small cell lung cancer who are being considered for treatment with dabrafenib (Tafinlar), pembrolizumab (Keytruda), or vemurafenib (Zelboraf);
More informationDrug Class Monograph
Drug Class Monograph Class: Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitor Drugs: Praluent (alirocumab), Repatha (evolocumab) Line of Business: Medi-Cal Effective Date: February 17, 2016
More informationDurlaza. Durlaza (aspirin) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.85.13 Subject: Durlaza Page: 1 of 4 Last Review Date: September 15, 2016 Durlaza Description Durlaza
More informationDaklinza Sovaldi. Daklinza (daclatasvir) and Sovaldi (sofosbuvir) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.01.36 Subject: Daklinza Page: 1 of 8 Last Review Date: March 18, 2016 Daklinza Description Daklinza (daclatasvir)
More informationAlimta (pemetrexed) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage
Alimta (pemetrexed) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date: 09/01/2007 Current Effective Date: TBD003/01/201703/01/2018 POLICY A. INDICATIONS The indications
More informationSTATIN UTILIZATION MANAGEMENT CRITERIA
STATIN UTILIZATION MANAGEMENT CRITERIA DRUG CLASS: HMG Co-A Reductase Inhibitors & Combinations Agents which require prior review: Advicor (niacin extended-release/lovastatin) Crestor (rosuvastatin)(5mg,10mg,
More informationContents Please refer to Medical Policy I-4, Hemophilia Treatment for additional information.
August 2018 In This Issue Coverage Guidelines Updated for Hemophilia Treatment... 2 Coverage Criteria Revised for Nusinersen (Spinraza)... 6 Coverage Guidelines Developed for Vestronidase Alpha (Mepsevii)...
More informationClinical Policy: Cetuximab (Erbitux) Reference Number: ERX.SPA.261 Effective Date:
Clinical Policy: (Erbitux) Reference Number: ERX.SPA.261 Effective Date: 12.01.18 Last Review Date: 11.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationClinical Policy: Nivolumab (Opdivo) Reference Number: CP.HNMC.27 Effective Date: Last Review Date: Line of Business: Medicaid - HNMC
Clinical Policy: (Opdivo) Reference Number: CP.HNMC.27 Effective Date: 07.01.17 Last Review Date: 02.18 Line of Business: Medicaid - HNMC Revision Log See Important Reminder at the end of this policy for
More informationNB Drug Plans Formulary Update
Bulletin #980 August 23, 2018 NB Drug Plans Formulary Update This update to the New Brunswick Drug Plans Formulary is effective August 23, 2018. Included in this bulletin: Regular Benefit Additions Special
More informationPolicy. Medical Policy Manual Approved Revised: Do Not Implement Until 3/2/19. Nivolumab (Intravenous)
Nivolumab (Intravenous) NDC CODE(S) 00003-3772-XX Opdivo 40 MG/4ML SOLN (B-M SQUIBB U.S. (PRIMARY CARE)) 00003-3774-XX Opdivo 100 MG/10ML SOLN (B-M SQUIBB U.S. (PRIMARY CARE)) 00003-3734-XX Opdivo 240
More informationClinical Policy: Erlotinib (Tarceva) Reference Number: CP.PHAR74 Effective Date: Last Review Date: Line of Business: Oregon Health Plan
Clinical Policy: (Tarceva) Reference Number: CP.PHAR74 Effective Date: 07.01.18 Last Review Date: 02.18 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the end of this policy
More informationPolicy. Medical Policy Manual Approved Revised: Do Not Implement until 6/30/2019. Nivolumab
Medical Manual Approved Revised: Do Not Implement until 6/30/2019 Nivolumab NDC CODE(S) 00003-3772-XX Opdivo 40 MG/4ML SOLN (B-M SQUIBB U.S. (PRIMARY CARE)) 00003-3774-XX Opdivo 100 MG/10ML SOLN (B-M SQUIBB
More informationStep Therapy Approval Criteria
Effective Date: 10/01/2016 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Cymbalta (duloxetine) 3. Dovonex (calcipotriene) 4. Enbrel (etanercept)
More informationGranix. Granix (tbo-filgrastim) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.85.16 Subject: Granix 1 of 6 Last Review Date: September 15, 2017 Granix Description Granix (tbo-filgrastim)
More informationIressa. Iressa (gefitinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Iressa Page: 1 of 5 Last Review Date: June 22, 2018 Iressa Description Iressa (gefitinib) Background
More informationDrug Prior Authorization Form Opdivo (nivolumab)
This document contains both information and form fields. To read information, use the Down Arrow from a form field. Drug Prior Authorization Form The purpose of this form is to obtain information required
More informationOral Chemotherapy Agents
Oral Chemotherapy Agents NEW ADVANCES IN TARGETED THERAPY, OVERCOMING BARRIERS AND PROMOTING ADHERENCE KATIE SIAS, PHARMD CLINICAL PHARMACY COORDINATOR HEMATOLOGY/ONCOLOGY MIDMICHIGAN MEDICAL CENTER -
More informationCorporate Medical Policy
Corporate Medical Policy Proteomic Testing for Targeted Therapy in Non-Small Cell Lung File Name: Origination: Last CAP Review: Next CAP Review: Last Review: proteomic_testing_for_targeted_therapy_in_non_small_cell_lung_cancer
More informationAETNA BETTER HEALTH Non-Formulary Prior Authorization guideline for Colony Stimulating Factor (CSF)
AETNA BETTER HEALTH Non-Formulary Prior Authorization guideline for Colony Stimulating Factor (CSF) Colony Stimulating Factor (CSF) Neupogen (filgrastim; G-CSF), Neulasta (peg-filgrastim; G-CSF); Neulasa
More informationHarvoni. Harvoni (ledipasvir & sofosbuvir) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Harvoni Page: 1 of 7 Last Review Date: June 19, 2015 Harvoni Description Harvoni (ledipasvir &
More informationXalkori. Xalkori (crizotinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.12 Subject: Xalkori Page: 1 of 6 Last Review Date: June 22, 2017 Xalkori Description Xalkori (crizotinib)
More informationFor peripheral blood stem cell (PBSC) mobilization prior to and during leukapheresis in cancer patients preparing to undergo bone marrow ablation
Last Review: 4/2010 NON-FORMULARY Clinical Guideline Neupogen (filgrastim; G-CSF), Neulasta (peg-filgrastim; G-CSF), Neumega (oprelvekin; rh-il-11), Leukine (sargramostim; GM-CSF) Indications Neupogen
More informationZomig. Zomig / Zomig-ZMT (zolmitriptan) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.22 Subject: Zomig Page: 1 of 5 Last Review Date: November 30, 2018 Zomig Description Zomig / Zomig-ZMT
More information1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)?
09/07/2016 Prior Authorization AETA BETTER HEALTH OF KETUCK (MEDICAID) PCSK9 Inhibitors (K88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Ipilimumab (Yervoy) Reference Number: CP.PHAR.319 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan Coding Implications Revision Log See Important
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Sargramostim (Leukine) Reference Number: CP.PHAR.295 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan Coding Implications Revision Log See Important
More informationYervoy. Yervoy (ipilimumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.13 Subject: Yervoy Page: 1 of 5 Last Review Date: September 15, 2017 Yervoy Description Yervoy (ipilimumab)
More informationONZETRA XSAIL (sumatriptan) nasal powder
ONZETRA XSAIL (sumatriptan) nasal powder 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 informationZomig. Zomig / Zomig-ZMT (zolmitriptan) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.22 Subject: Zomig Page: 1 of 5 Last Review Date: March 16, 2018 Zomig Description Zomig / Zomig-ZMT
More informationADMINISTRATIVE POLICY AND PROCEDURE
ADMINISTRATIVE POLICY PROCEDURE Policy #: Subject: PCSK9 INHIBITS (ex: Repatha) Section: Care Management Effective Date: January 1, 2015 Revision Date(s): NA Review Date(s): NA Responsible Parties: Patryce
More informationCyramza. Cyramza (ramucirumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.21.44 Subject: Cyramza Page: 1 of 6 Last Review Date: June 24, 2016 Cyramza Description Cyramza (ramucirumab)
More informationPharmacy Policy Bulletin
Pharmacy Policy Bulletin Title: Policy #: PCSK9 inhibitors Rx.01.170 Application of pharmacy policy is determined by benefits and contracts. Benefits may vary based on product line, group, or contract.
More information