Policy: Growth Hormones Reference Number: TCHP.PHAR.184 Effective Date: Last Review Date:

Size: px
Start display at page:

Download "Policy: Growth Hormones Reference Number: TCHP.PHAR.184 Effective Date: Last Review Date:"

Transcription

1 Policy: Growth Hormones Reference Number: TCHP.PHAR.184 Effective Date: Last Review Date: Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Goal(s): Restrict use of growth hormone (GH) for funded diagnoses where there is evidence of effectiveness and safety NOTE: Treatment with growth hormone (GH) is included only for children with: pituitary dwarfism, Turner s syndrome, Prader-Willi-syndrome, Noonan s syndrome, short stature homeobox-containing gene (SHOX), chronic kidney disease (stage 3 or higher) and those with renal transplant. Treatment with GH should continue only until adult height as determined by bone age is achieved. Treatment is not included for isolated deficiency of human growth hormone or other conditions in adults. Length of Authorization: Up to 12 months Requires PA: All GH products require prior authorization for OHP coverage. GH treatment for adults is not funded by the OHP. Covered Alternatives: Current Trillium Preferred Drug List listed at: o Approval Criteria 1. What is diagnosis is being treated? 2. Is the patient an adult (>18 years of age)? 3. Is this a request for initiation of growth hormone? Record ICD-10 code. Yes: Pass to RPh. Deny; not funded by the OHP Yes: Go to #4 4. Is the prescriber a pediatric endocrinologist or pediatric nephrologist? Yes: Go to #5 5. Is the diagnosis promotion of growth delay in a child with 3rd degree burns? 6. Is the diagnosis one of the following: Turner s syndrome (ICD-10 Q96.9) Noonan s syndrome (ICD-10 E78.71-E78.72, Q87.2-Q87.3, Q87.5, Q87.81, Q87.89, Q89.8) Prader-Willi syndrome (PWS) (ICD-10 Q87.1) Pituitary dwarfism (ICD-10 E23.0) Yes: Document and send to RPh for review. Yes: Document and go to #7 Page 1 of 5 No: Go to #3 No: Go to Renewal Criteria. No: Go to #6 not funded by the OHP.

2 Short stature homeobox-containing gene (SHOX) (ICD-10 R62.52) Chronic kidney disease (CKD, Stage 3) (ICD-10 N18.3-N18.5) Renal transplant (ICD-10 Z94.0) 7. If male, is bone age <16 years? If female, is bone age <14 years? Yes: Go to #8 8. Is there evidence of non-closure of ephiphyseal plate? Yes: Go to #9 9. Is the product requested preferred? Yes: Approve for up to 12 months Yes: Inform prescriber of covered alternatives in class and approve for up to 12 months. 10. Will the prescriber consider a change to a preferred product? Message: Preferred products are reviewed for comparative effectiveness and safety by the Oregon Pharmacy and Therapeutics (P&T) Committee. No: Pass to RPh. Deny;. No: Pass to RPH. Deny; No: Go to #10 No: Approve for up to 12 months. Renewal Criteria 1. Document approximate date of initiation of therapy and diagnosis (if not already done). 2. Is growth velocity greater than 2.5 cm per year? Yes: Go to #3 3. Is male bone age <16 years or female bone age Yes: Go to #4 <14 years? 4. Is the product requested preferred? Yes: Approve for up to 12 No: Go to #5 months 5. Will the prescriber consider a change to a Yes: Inform prescriber of No: Approve for up to preferred product? covered alternatives in 12 months. class and approve for up Message: to 12 months. Preferred products are reviewed for comparative effectiveness and safety by the Pharmacy and Therapeutics (P&T) Committee. I. General Information Preferred product: Norditropin Contraindications to GH Therapy o Hypersensitivity to somatropin or any diluents/excipients in the prescribed product, such as history of angioedema o Acute critical illness due to complications following open heart surgery, abdominal surgery or multiple accidental trauma o Acute respiratory failure o Active or suspected malignancy within the last 12 months Page 2 of 5

3 o Active proliferative or severe non-proliferative diabetic retinopathy o Epiphyseal closure o For Prader-Willi Syndrome: severe obesity The 2009 American Association of Clinical Endocrinologists (AACE) guidelines for clinical practice for growth hormone use in growth hormone-deficient adults and transition patients state that there is no evidence that one GH product is more advantageous over the other, apart from differences in pen devices, dose increments and decrements, and whether or not the product requires refrigeration; therefore, we do not recommend the use of one commercial GH preparation over another. GF-1 and IGFBP-3 levels should be interpreted against reference ranges that are standardized for sex and age (or better, by stage of sexual development, if available). The range varies with the assay used, and results should be interpreted against standards provided by the laboratory performing the test. II. Dosage and Administration Drug Name Indication Somatropin (Genotropin, Genotropin Miniquick, Humatrope, Humatrope Combo Pack, Norditropin Flexpro, Nutropin Aq Nuspin, Omnitrope, Saizen, Zomacton, Zorbtive) Serostim Nutropin AQ NuSpin Omnitrope Saizen Maximum Dose Refer to prescribing information (Somatropin, rh-gh doses must be individualized and are highly variable depending on the nature and severity of the disease, the formulation being used, and on patient response) Children and adolescents with GHD, small for gestational age, Turner syndrome, Prader- Willi syndrome, Noonan syndrome, SHOX deficiency, growth failure secondary to CKD, Adults with growth hormone deficiency, Short bowel syndrome Wasting or Cachexia < 35 kg = 0.1 mg/kg SC QHS 6 mg in HIV patients SC/day 35 to 45 kg = 4 mg SC QHS 45 kg to 55 kg = 5 mg SC QHS > 55 kg = 6 mg SC QHS III. Product Availability Drug Genotropin lyophilized powder Genotropin Miniquick (without preservative) Humatrope Norditropin Flexpro Dosing Regimen Availability Dual-chamber syringe: 5.8 mg, 12 mg Cartridge: 0.2 mg, 0.4 mg, 0.6 mg, 0.8 mg, 1.0 mg, 1.2 mg, 1.4 mg, 1.6 mg. 1.8 mg, and 2.0 mg Cartridge: 6 mg, 12 mg, 24 mg Vial: 5mg Pen: 5 mg/1.5 ml, 10 mg/1.5 ml, 15 mg/1.5 ml, 30 mg/3 ml Cartridge: 5 mg/2 ml Pen: 10 mg/2 ml, 20 mg/2 ml Cartridge:5 mg/1.5 ml, 10 mg/1.5 ml Dual-chamber syringe: 5.8 mg Cartridge: 8.8 mg Vial: 5 mg, 8.8 mg Page 3 of 5

4 Serostim Zomacton Zorbtive Vial: 4 mg, 5 mg, 6 mg Vial: 5 mg, 10 mg Vial: 8.8 mg IV. References 1. Growth Hormones. Oregon Health Plan Current Drug Use Criteria. Available at: Accessed March 19, Micromedex Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed March 19, Reviews, Revisions, and Approvals Date Policy created. Supersedes the following Centene Policies: CP.PHAR.55 Somatropin (Human Growth Hormone) P&T Approval Date Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of practice; peer-reviewed literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of practice current at the time that this clinical policy was approved. Health Plan means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan s affiliates, as applicable. The purpose of this clinical policy is to provide a guide to necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. This clinical policy does not constitute advice, treatment or care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional judgment in providing the most appropriate care, and are solely responsible for the advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Page 4 of 5

5 Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan. This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. Page 5 of 5

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. Policy: Atopic Dermatitis and Topical Antipsoriatics Reference Number: TCHP.PHAR.18004 Effective Date: 01.01.18 Last Review Date: 10.12.18 Line of Business: Oregon Health Plan Revision Log See Important

More information

Clinical Policy: Naloxone (Evzio) Reference Number: CP.PMN.139 Effective Date: Last Review Date: Line of Business: Commercial, Medicaid

Clinical Policy: Naloxone (Evzio) Reference Number: CP.PMN.139 Effective Date: Last Review Date: Line of Business: Commercial, Medicaid Clinical Policy: Naloxone (Evzio) Reference Number: CP.PMN.139 Effective Date: 11.16.16 Last Review Date: 08.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of

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: Lesinurad (Zurampic), Lesinurad/Allopurinol (Duzallo) Reference Number: CP.PMN.150 Effective Date: 11.16.16 Last Review Date: 08.18 Line of Business: Commercial, Medicaid See Important

More information

Clinical Policy: Somatropin (Serostim) Reference Number: CP.CPA.151 Effective Date: Last Review Date: Line of Business: Commercial

Clinical Policy: Somatropin (Serostim) Reference Number: CP.CPA.151 Effective Date: Last Review Date: Line of Business: Commercial Clinical Policy: (Serostim) Reference Number: CP.CPA.151 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for

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. Policy: Sodium-Glucose Co-Transpter 2 (SGLT2) Inhibits Reference Number: TCHP.PHAR.182 Effective Date: 07.01.18 Last Review Date: 04.13.18 Line of Business: Oregon Health Plan Revision Log See Imptant

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: 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 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: (Zurampic) Reference Number: CP.CPA.174 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

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: (Tagrisso) Reference Number: CP.PHAR.294 Effective Date: 12.01.16 Last Review Date: 08.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this

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: Darbepoetin Alfa (Aranesp) Reference Number: CP.PHAR.236 Effective Date: 06.01.16 Last Review Date: 05.18 Line of Business: HIM, Medicaid Coding Implications Revision Log See Important

More information

Clinical Policy: Nivolumab (Opdivo) Reference Number: CP.HNMC.27 Effective Date: Last Review Date: Line of Business: Medicaid - HNMC

Clinical 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 information

Clinical Policy: Cinacalcet (Sensipar) Reference Number: CP.PHAR.61 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Cinacalcet (Sensipar) Reference Number: CP.PHAR.61 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: (Sensipar) Reference Number: CP.PHAR.61 Effective Date: 05.01.11 Last Review Date: 02.18 Line of Business: Medicaid 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: Policy Reference Number: CP.PMN.53 Effective Date: 09.12.17 Last Review Date: 11.18 Line of Business: Medicaid, HIM-Medical Benefit Revision Log See Important Reminder at the end of this

More information

Clinical Policy: Trabectedin (Yondelis) Reference Number: CP.PHAR.204 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Trabectedin (Yondelis) Reference Number: CP.PHAR.204 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: (Yondelis) Reference Number: CP.PHAR.204 Effective Date: 05.01.16 Last Review Date: 02.18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end

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: Mecasermin (Increlex) Reference Number: CP.PHAR.150 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan Coding Implications Revision Log See Important

More information

Clinical Policy: Ramucirumab (Cyramza) Reference Number: CP.HNMC.09 Effective Date: Last Review Date: Line of Business: Medicaid - HNMC

Clinical Policy: Ramucirumab (Cyramza) Reference Number: CP.HNMC.09 Effective Date: Last Review Date: Line of Business: Medicaid - HNMC Clinical Policy: (Cyramza) Reference Number: CP.HNMC.09 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

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

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: (Glumetza) Reference Number: CP.PMN.72 Effective Date: 07.01.18 Last Review Date: 05.18 Line of Business: Oregon Health Plan 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: (Thyrogen) Reference Number: CP.PHAR.95 Effective Date: 03.12 Last Review Date: 08.18 Line of Business: Medicaid, HIM-Medical Benefit Revision Log See Important Reminder at the end of

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: (Xyrem) Reference Number: CP.CPA.172 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

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: (Krystexxa) Reference Number: CP.CPA.57 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

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: Lacosamide (Vimpat) Reference Number: CP.PMN.155 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the end

More information

FDA Approved Indication(s) Firmagon is indicated for treatment of advanced prostate cancer.

FDA Approved Indication(s) Firmagon is indicated for treatment of advanced prostate cancer. Clinical Policy: (Firmagon) Reference Number: CP.PHAR.170 Effective Date: 10.01.16 Last Review Date: 11.17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end

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: (Kadcyla) Reference Number: CP.PHAR.229 Effective Date: 06.01.16 Last Review Date: 05.18 Line of Business: Commercial, HIM-Medical Benefit, Medicaid 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: (Xofluza) Reference Number: CP.PMN.185 Effective Date: 10.30.18 Last Review Date: 11.18 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: Fluticasone/Salmeterol (Advair Diskus, Advair HFA) Reference Number: CP.PMN.31 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan See Important Reminder

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

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: Cerdelga, Zavesca Reference Number: CP.CPA.240 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

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: (Imfinzi) Reference Number: CP.PHAR.339 Effective Date: 07.01.17 Last Review Date: 05.18 Line of Business: Medicaid, HIM-Medical Benefit Coding Implications 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: Enfuvirtide (Fuzeon) Reference Number: CP.PHAR.41 Effective Date: 10.01.18 Last Review Date: 07.13.18 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the end

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: (Palynziq) Reference Number: CP.PHAR.140 Effective Date: 07.31.18 Last Review Date: 11.18 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the end of

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: (Krystexxa) Reference Number: CP.PHAR.115 Effective Date: 06.01.13 Last Review Date: 02.19 Line of Business: Commercial, Medicaid Coding Implications Revision Log See Important Reminder

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: (Daraprim) Reference Number: CP.PMN.44 Effective Date: 11.01.15 Last Review Date: 08.18 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the end of this

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: CP.CPA.241 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 information

Clinical Policy: Naltrexone (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Naltrexone (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: 03.01.12 Last Review Date: 02.19 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of

More information

Clinical Policy: Naltrexone (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Naltrexone (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: 03.01.12 Last Review Date: 02.18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of

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: (Iressa) Reference Number: CP.PHAR.68 Effective Date: 11.16.16 Last Review Date: 11.18 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: (Relistor) Reference Number: CP.CPA.274 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for

More information

Clinical Policy: Fluticasone/Salmeterol (Advair Diskus, Advair HFA) Reference Number: CP.PMN.31 Effective Date: 08/16 Last Review Date: 08/17

Clinical Policy: Fluticasone/Salmeterol (Advair Diskus, Advair HFA) Reference Number: CP.PMN.31 Effective Date: 08/16 Last Review Date: 08/17 Clinical Policy: (Advair Diskus, Advair HFA) Reference Number: CP.PMN.31 Effective Date: 08/16 Last Review Date: 08/17 Line of Business: Medicaid Revision Log See Important Reminder at the end of this

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: (Nerlynx) Reference Number: CP.PHAR.365 Effective Date: 09.05.17 Last Review Date: 11.18 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: (Portrazza) Reference Number: CP.PHAR.320 Effective Date: 03.01.17 Last Review Date: 11.18 Line of Business: Medicaid, HIM-Medical Benefit Coding Implications 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: (Fortamet, Glumetza) Reference Number: CP.PMN.72 Effective Date: 11.01.15 Last Review Date: 02.19 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end

More information

Clinical Policy: Tolvaptan (Jynarque, Samsca)

Clinical Policy: Tolvaptan (Jynarque, Samsca) Clinical Policy: (Jynarque, Samsca) Reference Number: CP.PHAR.27 Effective Date: 06.05.18 Last Review Date: 11.18 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the

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: Pellet (Testopel) Reference Number: CP.PHAR.354 Effective Date: 08.01.17 Last Review Date: 11.18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the

More information

Clinical Policy: Rivastigmine (Exelon) Reference Number: CP.PMN.101 Effective Date: Last Review Date: 02.18

Clinical Policy: Rivastigmine (Exelon) Reference Number: CP.PMN.101 Effective Date: Last Review Date: 02.18 Clinical Policy: (Exelon) Reference Number: CP.PMN.101 Effective Date: 03.01.17 Last Review Date: 02.18 Line of Business: Medicaid 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: (Sprycel) Reference Number: CP.PHAR.72 Effective Date: 07.01.18 Last Review Date: 05.18 Line of Business: Oregon Health Plan Revision Log See Important Reminder at the end of this policy

More information

Clinical Policy: Pegfilgrastim (Neulasta) Reference Number: CP.CPA.127 Effective Date: Last Review Date: Line of Business: Commercial

Clinical Policy: Pegfilgrastim (Neulasta) Reference Number: CP.CPA.127 Effective Date: Last Review Date: Line of Business: Commercial Clinical Policy: (Neulasta) Reference Number: CP.CPA.127 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for

More information

Clinical Policy: Buprenorphine-Naloxone (Bunavail, Suboxone, Zubsolv) Reference Number: CP.PMN.81 Effective Date: Last Review Date: 02.

Clinical Policy: Buprenorphine-Naloxone (Bunavail, Suboxone, Zubsolv) Reference Number: CP.PMN.81 Effective Date: Last Review Date: 02. Clinical Policy: (Bunavail, Suboxone, Zubsolv) Reference Number: CP.PMN.81 Effective Date: 09.01.17 Last Review Date: 02.18 Line of Business: Medicaid See Important Reminder at the end of this policy for

More information

General Approval Criteria for ALL Growth Hormone agents: (ALL criteria must be met)

General Approval Criteria for ALL Growth Hormone agents: (ALL criteria must be met) Growth Hormone Agents Prior Authorization Criteria for Louisiana Fee for Service and MCO Medicaid Recipients Page 1 of 7 Preferred Agents Somatropin Pen (Norditropin ) Somatropin Pen (Nutropin AQ ) Non-Preferred

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: 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 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: (Ajovy) Reference Number: CP.PHAR.## Effective Date: 10.30.18 Last Review Date: 02.19 Line of Business: Commercial, TBD HIM*, Medicaid Revision Log See Important Reminder at the end of

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

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: (Famvir) Reference Number: HIM.PA.63 Effective Date: 12/14 Last Review Date: 08/17 Line of Business: Health Insurance Marketplace Revision Log See Important Reminder at the end of this

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: (Glumetza, Fortamet) Reference Number: CP.HNCA.72 Effective Date: 11.01.15 Last Review Date: 05.18 Line of Business: Commercial - HNCA Revision Log See Important Reminder at the end of

More information

Clinical Policy: Dabrafenib (Tafinlar) Reference Number: CP.PHAR.239 Effective Date: 07/16 Last Review Date: 07/17 Line of Business: Medicaid

Clinical Policy: Dabrafenib (Tafinlar) Reference Number: CP.PHAR.239 Effective Date: 07/16 Last Review Date: 07/17 Line of Business: Medicaid Clinical Policy: (Tafinlar) Reference Number: CP.PHAR.239 Effective Date: 07/16 Last Review Date: 07/17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of

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: (Priftin) Reference Number: CP.PMN.05 Effective Date: 07.01.18 Last Review Date: 02.18 Line of Business: Oregon Helath Plan 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: Reference Number: HIM.PA.59 Effective Date: 12/14 Last Review Date: 08/17 Line of Business: Health Insurance Marketplace Coding Implications Revision Log See Important Reminder at the

More information

Clinical Policy: Netupitant and Palonosetron (Akynzeo) Reference Number: HIM.PA.113 Effective Date: Last Review Date: 05.

Clinical Policy: Netupitant and Palonosetron (Akynzeo) Reference Number: HIM.PA.113 Effective Date: Last Review Date: 05. Clinical Policy: (Akynzeo) Reference Number: HIM.PA.113 Effective Date: 05.01.17 Last Review Date: 05.18 Line of Business: HIM Revision Log See Important Reminder at the end of this policy for important

More information

Clinical Policy: Nilotinib (Tasigna) Reference Number: CP.CPA.162 Effective Date: Last Review Date: Line of Business: Commercial

Clinical Policy: Nilotinib (Tasigna) Reference Number: CP.CPA.162 Effective Date: Last Review Date: Line of Business: Commercial Clinical Policy: (Tasigna) Reference Number: CP.CPA.162 Effective Date: 11.16.16 Last Review Date: 11.17 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: (Caprelsa) Reference Number: CP.PHAR.80 Effective Date: 10.01.11 Last Review Date: 02.18 Line of Business: Health Insurance Marketplace, Medicaid Revision Log See Important Reminder at

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

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

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: (Aimovig) Reference Number: CP.PHAR.128 Effective Date: 07.10.18 Last Review Date: 08.18 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: Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) Reference Number: CP.PHAR.228 Effective Date: 07.01.18 Last Review Date: 05.18 Line of Business: Oregon Health Plan Coding Implications

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: (Verzenio) Reference Number: CP.PHAR.355 Effective Date: 10.24.17 Last Review Date: 05.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this

More information

Clinical Policy: Infertility Therapy Reference Number: CP.CPA.261 Effective Date: Last Review Date: Line of Business: Medicaid Medi-Cal

Clinical Policy: Infertility Therapy Reference Number: CP.CPA.261 Effective Date: Last Review Date: Line of Business: Medicaid Medi-Cal Clinical Policy: Reference Number: CP.CPA.261 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 information

Clinical Policy: Topotecan (Hycamtin) Reference Number: CP.PHAR.64 Effective Date: Last Review Date: Line of Business: Medicaid, HIM

Clinical Policy: Topotecan (Hycamtin) Reference Number: CP.PHAR.64 Effective Date: Last Review Date: Line of Business: Medicaid, HIM Clinical Policy: (Hycamtin) Reference Number: CP.PHAR.64 Effective Date: 06.01.11 Last Review Date: 05.18 Line of Business: Medicaid, HIM Coding Implications Revision Log See Important Reminder at the

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

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: (Human Growth Hormone) Reference Number: CP.CPA.84 Effective Date: 11.16.16 Last Review Date: 05.18 Line of Business: Commercial Revision Log See Important Reminder at the end of this

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

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: (Lynparza) Reference Number: CP.PHAR.360 Effective Date: 10.03.17 Last Review Date: 02.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this

More information

GROWTH HORMONE THERAPY

GROWTH HORMONE THERAPY GROWTH HORMONE THERAPY Line(s) of Business: HMO; PPO; QUEST Integration Original Effective Date: 05/21/1999 Current Effective Date: 10/01/2015 POLICY A. INDICATIONS The indications below including FDA-approved

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

GROWTH HORMONE THERAPY

GROWTH HORMONE THERAPY GROWTH HORMONE THERAPY Line(s) of Business: HMO; PPO; QUEST Integration Original Effective Date: 05/21/1999 Current Effective Date: 03/01/201804/01/2019 POLICY A. INDICATIONS The indications below including

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: NE.PMN.68 Effective Date: 01/01/2017 Last Review Date: Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of this

More information

Clinical Policy: Erlotinib (Tarceva) Reference Number: CP.PHAR74 Effective Date: Last Review Date: Line of Business: Oregon Health Plan

Clinical 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 information

Clinical Policy: Pasireotide (Signifor LAR) Reference Number: CP.PHAR.332 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Pasireotide (Signifor LAR) Reference Number: CP.PHAR.332 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: (Signifor LAR) Reference Number: CP.PHAR.332 Effective Date: 03.01.17 Last Review Date: 11.17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the

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

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: (Mekinist) Reference Number: CP.PHAR.240 Effective Date: 07.01.16 Last Review Date: 08.18 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the end of

More information

Clinical Policy: Roflumilast (Daliresp) Reference Number: CP.PMN.46. Line of Business: Medicaid

Clinical Policy: Roflumilast (Daliresp) Reference Number: CP.PMN.46. Line of Business: Medicaid Clinical Policy: (Daliresp) Reference Number: CP.PMN.46 Effective Date: 11/11 Last Review Date: 08/17 Line of Business: Medicaid 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: (Vyxeos) Reference Number: CP.PHAR.352 Effective Date: 12.01.17 Last Review Date: 11.18 Line of Business: Medicaid, HIM-Medical Benefit Coding Implications Revision Log See Important Reminder

More information

Clinical Policy: Pralatrexate (Folotyn) Reference Number: CP.PHAR.313 Effective Date: Last Review Date: Line of Business: Medicaid

Clinical Policy: Pralatrexate (Folotyn) Reference Number: CP.PHAR.313 Effective Date: Last Review Date: Line of Business: Medicaid Clinical Policy: (Folotyn) Reference Number: CP.PHAR.313 Effective Date: 02.01.17 Last Review Date: 11.17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of

More information

Clinical Policy: Budesonide (Uceris) Reference Number: CP.PCH.11 Effective Date: Last Review Date: Line of Business: Commercial, HIM*

Clinical Policy: Budesonide (Uceris) Reference Number: CP.PCH.11 Effective Date: Last Review Date: Line of Business: Commercial, HIM* Clinical Policy: (Uceris) Reference Number: CP.PCH.11 Effective Date: 08.14.18 Last Review Date: 11.18 Line of Business: Commercial, HIM* Revision Log See Important Reminder at the end of this policy for

More information

GROWTH HORMONE THERAPY

GROWTH HORMONE THERAPY GROWTH HORMONE THERAPY Line(s) of Business: HMO; PPO; QUEST Integration Original Effective Date: 05/21/1999 Current Effective Date: 12/30/201601/01/2018TBD03/01/2018 POLICY A. INDICATIONS The indications

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: (Lotronex) Reference Number: CP.PMN.153 Effective Date: 11.16.16 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: Asfotase Alfa (Strensiq) Reference Number: CP.PHAR.328 Effective Date: Last Review Date: 11.17

Clinical Policy: Asfotase Alfa (Strensiq) Reference Number: CP.PHAR.328 Effective Date: Last Review Date: 11.17 Clinical Policy: (Strensiq) Reference Number: CP.PHAR.328 Effective Date: 03.01.17 Last Review Date: 11.17 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important

More information

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

Revision Log. See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: (Kuvan) Reference Number: CP. PHAR.43 Effective Date: 02.01.10 Last Review Date: 02.18 Line of Business: Medicaid 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: (Caduet) Reference Number: CP.CPA.237 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

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: (Verzenio) Reference Number: CP.PHAR.355 Effective Date: 10.24.17 Last Review Date: 02.19 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this

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: (Trogarzo) Reference Number: CP.PHAR.378 Effective Date: 04.17.18 Last Review Date: 05.18 Line of Business: Commercial, HIM-Medical Benefit, Medicaid 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: Reference Number: CP.PMN.04 Effective Date: 11.15.17 Last Review Date: 05.18 Line of Business: Commercial, Medicaid 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

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: Methoxy polyethylene glycol-epoetin beta (Mircera) Reference Number: CP.CPA.322 Effective Date: 06.01.18 Last Review Date: 05.18 Line of Business: Commercial Coding Implications Revision

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: (Strensiq) Reference Number: CP.PHAR.328 Effective Date: 03.01.17 Last Review Date: 11.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of this

More information