FYI ONLY Generic Name. Generics available. zoledronic acid N/A

Size: px
Start display at page:

Download "FYI ONLY Generic Name. Generics available. zoledronic acid N/A"

Transcription

1 Criteria Document: Reference #: PC/A011 Page 1 of 5 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan (PCHP) PreferredOne Insurance Company (PIC) Individual PreferredOne Insurance Company (PIC) Large Group PreferredOne Insurance Company (PIC) Small Group PURPOSE: The intent of the criteria document is to: Ensure the intended use is medically necessary; and Require a failed trial of oral/self-administered drug(s) before an infused/subcutaneous drug for osteopenia, osteoporosis; and To consider overall cost effectiveness where it is appropriate. Table 1: Infused/Subcutaneous Drugs Drugs Boniva zoledronic acid Route of Administration intravenous injection subcutaneous injection administered by a healthcare professional intravenous infusion Generics available FYI ONLY Generic Name Drug Class N ibandronate bisphosphonate N/A denosumab monoclonal antibody N/A zoledronic acid bisphosphonate GUIDELINES: Medical Necessity Criteria Must satisfy one of the following: I - III I. Initial request for Boniva injection,, or zoledronic acid (Reclast) for prevention and/or treatment of osteopenia and/or osteoporosis must have one of the following: A-D A. The member has not responded to, is intolerant to, responds to but cannot taper off without recurrent symptoms, or is a poor candidate two oral/self-administered /non-infused drugs (see Table 2) with different mechanisms of action, ie, from different drug classes; or B. The request is for, and the member has severe renal impairment/chronic kidney disease (CKD) with a creatinine clearance less than 35mL/min; or C. The member has a pre-existing condition that precludes the use of an oral bisphosphonate, such as but not limited to one of the following: The member cannot swallow; or 2. The member has abnormalities that delay esophageal emptying (stricture, achalasia); or 3. The member has esophageal lesions or esophageal ulcers; or 4. The member cannot remain in an upright position post oral administration; or 5. The member is status post restrictive bariatric procedure.

2 Criteria Document: Reference #: PC/A011 Page 2 of 5 D. The member has gastroesophageal reflux disease (GERD) symptoms from a trial of oral bisphosphonates documentation of both of the following: 1 and 2 1. Patient education regarding taking medication with adequate amount of water while in an upright position, taking at an appropriate interval prior to or after the first food or drink of day, remaining in an upright position for a period of time after taking the medication; and 2. Persistent GERD symptoms despite adequate treatment with use of H2-blockers or proton pump inhibitors. Table 2: Oral/Self-Administered/Non-infused Medications* FYI ONLY DRUGS Route of Generics Biosimilars DRUG CLASS Generic Name Administration available available Actonel oral N N/A risedronate tablets bisphosphonate 5mg, 30mg, 35mg risedronate 150mg tablets oral N/A N/A risedronate tablets bisphosphonate Boniva oral Y N/A ibandronate tablets bisphosphonate selective estrogen Evista oral Y N/A raloxifene tablets receptor modulator recombinant human subcutaneous Forteo N N/A teriparatide parathyroid hormone injection (PTH) alendronate tablets Fosamax oral Y N/A bisphosphonate & oral solution * Listing of drugs in table above does not ensure coverage. Please check member s prescription benefit. Revised 11/09/16 II. Initial request for other diagnoses must have one of the following: A-C A. Initial request for pamidronate - must have one of the following: Bone metastasis from breast cancer; or 2. Hypercalcemia of malignancy; or 3. Paget s disease that has not responded to, is intolerant to, responds to but cannot taper off without recurrent symptoms, or is a poor candidate for one oral and/or self-administered drug(s); or 4. Multiple myeloma. B. Initial request for Xgeva must have one of the following: Hypercalcemia of malignancy; or 2. Bone metastases from solid tumors, for prevention of skeletal-related events; or 3. Giant cell tumor of bone that is unresectable or where surgical resection is likely to result in severe morbidity, for treatment of adults and skeletally mature adolescents. C. Initial request for zoledronic acid (Zometa) - must have one of the following: Adjuvant therapy in premenopausal women with estrogen-responsive early stage breast cancer and are receiving endocrine or hormone suppression therapy (eg, tamoxifen); or 2. Bone metastasis from solid tumors; or 3. Hypercalcemia of malignancy; or 4. Paget s disease that has not responded to, is intolerant to, responds to but cannot taper off without recurrent symptoms, or is a poor candidate for one oral and/or self-administered drug(s); or

3 Criteria Document: Reference #: PC/A011 Page 3 of 5 5. Multiple myeloma. III. Continuation request must meet both of the following: A and B A. The member has been previously approved by PreferredOne for the medication being requested; and B. There has been a positive clinical response to therapy, ie, no deterioration of bone density T-score, or an increase in bone density T-score. DEFINITIONS: T-score: A measurement of bone density compared with what is normally expected in a healthy young adult of the same gender. It is expressed in number of units (standard deviations) that the bone density is above or below the average. T-score What the score means -1 and above Bone density is considered normal. Between -1 and -2.5 A sign of osteopenia, a condition in which bone density is below normal and may lead to osteoporosis. 2.5 and below Likely have osteoporosis BACKGROUND: This criteria document is based on U.S. Food and Drug Administration (FDA) approved indications and dosing, expert consensus opinion and/or available reliable evidence.

4 Criteria Document: Reference #: PC/A011 Page 4 of 5 FOR INTERNAL USE ONLY COVERAGE: Prior Authorization: Yes - initial authorize for 12 months; continued use, authorize for 24 months Coverage is subject to the member s contract benefits. CODING: HCPCs J0897 injection, denosumab 1mg J1740 injection, ibandronate sodium, 1 mg J2430 injection, pamidronate disodium, per 30mg J3489 injection, zoledronic acid, 1mg Coverage is subject to the terms of a member s benefit plan. To the extent there is any inconsistency between this criteria document or policy and the terms of a member s benefit plan, the member s benefit plan governs. Approval of a drug under this criteria document does not ensure full coverage of the drug. RELATED CRITERIA/POLICIES: Integrated Healthcare Services Process Manual: UR015 Use of Medical Policy and Criteria REFERENCES: 1. National Osteoporosis Foundation. Clinician s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; National Pharmaceutical Services. Drug Class Review Parenteral Bisphosphonates Agents National Pharmaceutical Services. Drug Class Review Metabolic Bone Disease Agents, Others Gnant M, Mlineritsch B, Stoeger, H, et al. Adjuvant endocrine therapy plus zoledronic acid in premenopausal women with early-stage breast cancer: 62-month follow-up from the ABSCG-12 randomised trial. Lancet Oncolo Jul;12(7): Valachis A, Polyzos NP, Coleman RE, Gnant M, et al. Adjuvant therapy with zoledronic acid in patients with breast cancer; a systematic review and meta-analysis. Oncologist 2013;18(4): HeM, Fan W, Zhang X. Adjuvant zoledronic acid therapy for patients with early stage breast cancer: an updated systematic review and meta-analysis. J Hematol Oncol Oct 23;6(1): Boniva injection [package insert]. South San Francisco, CA: Genentech USA, Inc; Pamidronate [package insert]. Bedford, OH: Bedford Laboratories; Reclast [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; Zometa [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; Zoledronic acid [package insert]. Schaumberg, IL: Sagent Pharmaceuticals; 2015 DOCUMENT HISTORY: Created Date: 09/30/16 (previously part of PC/B009) Reviewed Date: Revised Date: 02/13/17, 03/20/17

5 Attachment A INDICATIONS Treatment of osteoporosis in postmenopausal women DRUGS Boniva pamidronate zoledronic acid denosumab X Treatment and prevention of postmenopausal osteoporosis Reclast Tx to increase bone mass in men with osteoporosis Reclast Treatment and prevention of glucocorticoid- induced osteoporosis Reclast Treatment of hypercalcemia of malignancy Treatment of osteolytic bone metastases of breast cancer or osteolytic lesions of multiple myeloma, in conjunction with standard antineoplastic therapy Treatment for patients with multiple myeloma & patients with documented bone metastases from solid tumors, in conjunction with standard antineoplastic therapy. Prostate cancer should have progressed after treatment with at least one hormonal therapy. Treatment of Paget s disease of bone in men and women Treatment to increase bone mass in men at high risk for fracture receiving androgen deprivation therapy for nonmetastatic prostate cancer. Treatment to increase bone mass in women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer. Prevention of skeletal-related events in patients with bone metastases from solid tumors Treatment of adults and skeletally mature adolescents with giant cell tumor of bone (GCTB) that is unresectable or where surgical resection is likely to result in severe morbidity. X Zometa Xgeva X Zometa X Reclast Xgeva Xgeva Revised 10/03/2016

6 PreferredOne Community Health Plan Nondiscrimination Notice PreferredOne Community Health Plan ( PCHP ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PCHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Community Health Plan PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Language Assistance Services NDR PCHP LV (10/16)

7 PreferredOne Insurance Company Nondiscrimination Notice PreferredOne Insurance Company ( PIC ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PIC: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact a Grievance Specialist. If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Grievance Specialist PreferredOne Insurance Company PO Box Minneapolis, MN Phone: (TTY: ) Fax: customerservice@preferredone.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Grievance Specialist is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at Language Assistance Services NDR PIC LV (10/16)

Approval of a drug under this criteria document does not ensure full coverage of the drug.

Approval of a drug under this criteria document does not ensure full coverage of the drug. Criteria Document: Reference #: PC/A011 Page 1 of 8 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community

More information

Department of Origin: Integrated Healthcare Services. Approved by: Chief Medical Officer Department(s) Affected: Date approved: 01/10/17

Department of Origin: Integrated Healthcare Services. Approved by: Chief Medical Officer Department(s) Affected: Date approved: 01/10/17 Reference #: MP/D005 Page: 1 of 3 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan

More information

06/13/17. A. Completed a comprehensive diabetes education program within the past two years; and

06/13/17. A. Completed a comprehensive diabetes education program within the past two years; and Reference #: MC/L011 Page 1 of 4 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA

More information

01/10/17. Replaces Effective Policy Dated: Amino Acid Based Elemental Formula (AABF) 09/28/15 Reference #: MP/A003 Page: 1 of 3

01/10/17. Replaces Effective Policy Dated: Amino Acid Based Elemental Formula (AABF) 09/28/15 Reference #: MP/A003 Page: 1 of 3 Reference #: MP/A003 Page: 1 of 3 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan

More information

03/13/18. A. Symptoms lasting for greater than or equal to 12 months that have resulted to significant impairment in activities of daily living; and

03/13/18. A. Symptoms lasting for greater than or equal to 12 months that have resulted to significant impairment in activities of daily living; and Reference #: MC/I008 Page: 1 of 5 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan

More information

01/26/17. Replaces Effective Policy Dated: Autism Spectrum Disorders in Children: Assessment 01/19/16 and Evaluation Reference #: MP/A005 Page 1 of 4

01/26/17. Replaces Effective Policy Dated: Autism Spectrum Disorders in Children: Assessment 01/19/16 and Evaluation Reference #: MP/A005 Page 1 of 4 Reference #: MP/A005 Page 1 of 4 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan

More information

TYMLOS (abaloparatide)

TYMLOS (abaloparatide) TYMLOS (abaloparatide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

PURPOSE: The intent of this policy is to provide guidelines for coverage of dental procedures under the medical benefit.

PURPOSE: The intent of this policy is to provide guidelines for coverage of dental procedures under the medical benefit. Integrated Reference #: MP/D009 Page 1 of 4 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc.

More information

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES

HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES Generic Brand HICL GCN Exception/Other PROLIA, XGEVA 37012 If the caller wishes to initiate a request then a MRF must be completed. This drug requires a written request for prior authorization. All requests

More information

BONIVA (ibandronate sodium)

BONIVA (ibandronate sodium) BONIVA (ibandronate sodium) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

Approved by: Integrated Health Quality Management Subcommittee Effective Date: Department of Origin: Integrated Healthcare Services.

Approved by: Integrated Health Quality Management Subcommittee Effective Date: Department of Origin: Integrated Healthcare Services. Reference #: MC/M020 Page 1 of 5 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan

More information

Prior Authorization Required: Yes as shown below

Prior Authorization Required: Yes as shown below PROLIA, XGEVA (denosumab) MB9409 Covered Service: Prior Authorization Required: Additional Information Medicare Policy: BadgerCare Plus Policy: Yes when meets criteria below Yes as shown below Must be

More information

Osteoporosis Agents Drug Class Prior Authorization Protocol

Osteoporosis Agents Drug Class Prior Authorization Protocol Osteoporosis 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

More information

09/12/17. I. Electrical Bone Growth Stimulator (invasive, semi-invasive, or non-invasive) any of the following: A-C

09/12/17. I. Electrical Bone Growth Stimulator (invasive, semi-invasive, or non-invasive) any of the following: A-C Reference #: MC/F021 Page: 1 of 4 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan

More information

Date approved: 04/18/18. Approved by: Pharmacy and Therapeutics Quality Management Subcommittee Effective Date: Department of Origin: Pharmacy

Date approved: 04/18/18. Approved by: Pharmacy and Therapeutics Quality Management Subcommittee Effective Date: Department of Origin: Pharmacy Integrated Healthcare Services and Criteria Document: Reference #: PC/V001 Page: 1 of 9 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services,

More information

03/14/17. II. Initial early intensive-level behavioral and developmental therapy must have both of the following: A and B

03/14/17. II. Initial early intensive-level behavioral and developmental therapy must have both of the following: A and B Reference #: MC/M024 Page 1 of 6 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan

More information

PROLIA: Medical Coverage Policy Denosumab (Prolia and. Xgeva) EFFECTIVE DATE: POLICY LAST UPDATED:

PROLIA: Medical Coverage Policy Denosumab (Prolia and. Xgeva) EFFECTIVE DATE: POLICY LAST UPDATED: Medical Coverage Policy Denosumab (Prolia and Xgeva) EFFECTIVE DATE: 11 01 2016 POLICY LAST UPDATED: 12 19 2017 OVERVIEW Prolia (denosumab) is indicated for the treatment of postmenopausal women with osteoporosis

More information

This Coverage Policy applies to Individual Health Insurance Marketplace benefit plans only.

This Coverage Policy applies to Individual Health Insurance Marketplace benefit plans only. This Coverage Policy applies to Individual Health Insurance Marketplace benefit plans only. INJECTABLE OSTEOPOSIS AGENTS SUBJECT Pharmacologic Agents: Bisphosphonates: Boniva IV (ibandronate) Reclast (zoledronic

More information

AETNA BETTER HEALTH Prior Authorization guideline for Injectable Osteoporosis Agents

AETNA BETTER HEALTH Prior Authorization guideline for Injectable Osteoporosis Agents AETNA BETTER HEALTH Prior Authorization guideline for Injectable Osteoporosis Agents Injectable Osteoporosis Agents Forteo (teriparatide); zoledronic acid Prolia (denosumab)] Authorization guidelines For

More information

RADIOFREQUENCY ABLATION OF MISCELLANEOUS SOLID TUMORS EXCLUDING LIVER TUMORS

RADIOFREQUENCY ABLATION OF MISCELLANEOUS SOLID TUMORS EXCLUDING LIVER TUMORS EXCLUDING LIVER TUMORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

Xgeva. Xgeva (denosumab) Description

Xgeva. Xgeva (denosumab) Description Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.30.18 Subject: Xgeva Page: 1 of 5 Last Review Date: March 16, 2018 Xgeva Description Xgeva (denosumab)

More information

STELARA (ustekinumab)

STELARA (ustekinumab) STELARA (ustekinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

ENTYVIO (vedolizumab)

ENTYVIO (vedolizumab) ENTYVIO (vedolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

B. To assess an individual when clinical evaluation suggests use of non-prescribed medications or illegal substances; or

B. To assess an individual when clinical evaluation suggests use of non-prescribed medications or illegal substances; or Integrated Reference #: MP/D010 Page: 1 of 7 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services,

More information

Xgeva. Xgeva (denosumab) Description. Section: Prescription Drugs Effective Date: January 1, 2016

Xgeva. Xgeva (denosumab) Description. Section: Prescription Drugs Effective Date: January 1, 2016 Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.07.18 Subject: Xgeva Page: 1 of 5 Last Review Date: December 3, 2015 Xgeva Description Xgeva (denosumab)

More information

Pharmacy Management Drug Policy

Pharmacy Management Drug Policy SUBJECT: - Forteo (teriparatide), Prolia (denosumab), Tymlos (abaloparatide) POLICY NUMBER: Pharmacy-35 EFFECTIVE DATE: 9/07 LAST REVIEW DATE: 9/29/2017 If the member s subscriber contract excludes coverage

More information

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

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: (Prolia, Xgeva) Reference Number: CP.PHAR.58 Effective Date: 03.01.11 Last Review Date: 05.18 Line of Business: Commercial, Medicaid Coding Implications Revision Log See Important Reminder

More information

GENETIC TESTING FOR TAMOXIFEN TREATMENT

GENETIC TESTING FOR TAMOXIFEN TREATMENT GENETIC TESTING FOR TAMOXIFEN TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical

More information

Pharmacy Medical Policy Bisphosphonates and Monoclonal Antibodies, Infusion/Injection

Pharmacy Medical Policy Bisphosphonates and Monoclonal Antibodies, Infusion/Injection Pharmacy Medical Policy Bisphosphonates and Monoclonal Antibodies, Infusion/Injection Table of Contents Policy: Commercial Policy History References Coding Information Information Pertaining to All Policies

More information

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

MEDICAL COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 10/04/17 SECTION: DRUGS LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE: BAVENCIO (avelumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

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: (Prolia, Xgeva) Reference Number: CP.PHAR.58 Effective Date: 03.01.11 Last Review Date: 02.19 Line of Business: Commercial, HIM, Medicaid Coding Implications Revision Log See Important

More information

Pharmacy Management Drug Policy

Pharmacy Management Drug Policy Clinical criteria used to make utilization review decisions are based on credible scientific evidence published in peer reviewed medical literature generally recognized by the medical community. Guidelines

More information

Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Drug List

Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Drug List Upcoming Changes to Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 Drug List Updated 8/1/2017 Santa Clara Family Health Plan (SCFHP) Cal MediConnect Plan (Medicare-Medicaid

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: denosumab_prolia_xgeva 3/2011 9/2017 9/2018 9/2017 Description of Procedure or Service Receptor activator

More information

Pharmacy Management Drug Policy

Pharmacy Management Drug Policy SUBJECT: - Forteo (teriparatide), Prolia (denosumab), Tymlos (abaloparatide), Boniva injection (Ibandronate) POLICY NUMBER: Pharmacy-35 EFFECTIVE DATE: 9/07 LAST REVIEW DATE: 10/15/2018 If the member s

More information

PARSABIV (etelcalcetide)

PARSABIV (etelcalcetide) PARSABIV (etelcalcetide) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and

More information

Calendar Year Deductible Annual Benefit Maximum. ADA Code Covered Services Member pays

Calendar Year Deductible Annual Benefit Maximum. ADA Code Covered Services Member pays An independent member of the Blue Shield Association A50861-SG (1/19) Dental HMO Plan Dental HMO Standard Benefit summary Effective January 1, 2019 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE

More information

Calendar Year Deductible Annual Benefit Maximum. ADA Code Covered Services Member pays. n/a Office visit $5 per visit

Calendar Year Deductible Annual Benefit Maximum. ADA Code Covered Services Member pays. n/a Office visit $5 per visit Blue Shield of California Dental HMO Plan Dental HMO Basic Benefit summary Effective January 1, 2018 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE

More information

4.7 Studies of Quality Holy Cross Hospital Bone Health Early Stage I ER/PR Positive Breast Cancer Patients December 13, 2017

4.7 Studies of Quality Holy Cross Hospital Bone Health Early Stage I ER/PR Positive Breast Cancer Patients December 13, 2017 4.7 Studies of Quality Holy Cross Hospital 2017 Bone Health Early Stage I ER/PR Positive Breast Cancer Patients December 13, 2017 Bone Health in Stage I ER/PR Positive Breast Cancer Patients To review

More information

PERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES

PERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES PERJETA (pertuzumab) FOR TREATMENT OF MALIGNANCIES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,

More information

LARTRUVO (olaratumab)

LARTRUVO (olaratumab) LARTRUVO (olaratumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

PANCREATIC ISLET TRANSPLANT

PANCREATIC ISLET TRANSPLANT PANCREATIC ISLET TRANSPLANT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

RELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE

RELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE RELISTOR (methylnaltrexone bromide) INJECTION FOR SUBCUTANEOUS USE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for

More information

Medication Policy Manual. Topic: Prolia, denosumab Date of Origin: August 11, 2010

Medication Policy Manual. Topic: Prolia, denosumab Date of Origin: August 11, 2010 Independent licensees of the Blue Cross and Blue Shield Association Medication Policy Manual Policy No: dru223 Topic: Prolia, denosumab Date of Origin: August 11, 2010 Committee Approval Date: August 11,

More information

GENETIC TESTING FOR PREDICTING RISK OF NONFAMILIAL BREAST CANCER

GENETIC TESTING FOR PREDICTING RISK OF NONFAMILIAL BREAST CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon

More information

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: (Reclast, Zometa) Reference Number: CP.PHAR.59 Effective Date: 03.11 Last Review Date: 02.18 Line of Business: Commercial, Medicaid Coding Implications Revision Log See Important Reminder

More information

2018 Preventive Schedule

2018 Preventive Schedule 2018 Preventive Schedule Medicare-Covered Services PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT Preventive or routine care helps us stay well or finds problems early, when they are easier to treat.

More information

Smile SM Plus 50/1500/Ortho/MAC

Smile SM Plus 50/1500/Ortho/MAC Dental PPO Plan Smile SM Plus 50/1500/Ortho/MAC Benefit summary Effective January 1, 2019 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF

More information

GATTEX (teduglutide [rdna origin])

GATTEX (teduglutide [rdna origin]) GATTEX (teduglutide [rdna origin]) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

Smile SM Value 50/1500/No Ortho/MAC

Smile SM Value 50/1500/No Ortho/MAC Blue Shield of California Dental PPO Plan Smile SM Value 50/1500/No Ortho/MAC Benefit summary Effective January 1, 2018 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A

More information

RADIOFREQUENCY ABLATION OF PRIMARY OR METASTATIC LIVER TUMORS

RADIOFREQUENCY ABLATION OF PRIMARY OR METASTATIC LIVER TUMORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent upon

More information

IMMUNE CELL FUNCTION ASSAY

IMMUNE CELL FUNCTION ASSAY IMMUNE CELL FUNCTION ASSAY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and

More information

ALPHA1-PROTEINASE INHIBITORS

ALPHA1-PROTEINASE INHIBITORS ALPHA1-PROTEINASE INHIBITORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

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

DRUG TESTING IN PAIN MANAGEMENT AND SUBSTANCE USE DISORDER(S) TREATMENT TREATMENT Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent

More information

Smile SM Deluxe Gold 50/1500/Ortho/U85

Smile SM Deluxe Gold 50/1500/Ortho/U85 Blue Shield of California Dental PPO Plan Smile SM Deluxe Gold 50/1500/Ortho/U85 Benefit summary Effective January 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS

More information

INTRACAVITARY BALLOON BRACHYTHERAPY FOR MALIGNANT AND METASTATIC BRAIN TUMORS

INTRACAVITARY BALLOON BRACHYTHERAPY FOR MALIGNANT AND METASTATIC BRAIN TUMORS METASTATIC BRAIN TUMORS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and

More information

SOMATULINE DEPOT (lanreotide acetate)

SOMATULINE DEPOT (lanreotide acetate) SOMATULINE DEPOT (lanreotide acetate) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical

More information

ENDOBRONCHIAL ULTRASOUND FOR DIAGNOSIS AND STAGING OF LUNG CANCER

ENDOBRONCHIAL ULTRASOUND FOR DIAGNOSIS AND STAGING OF LUNG CANCER CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent

More information

MULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER

MULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER MULTIMARKER SERUM TESTING RELATED TO OVARIAN CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,

More information

ORAL IMPLANT PROCEDURES

ORAL IMPLANT PROCEDURES ORAL IMPLANT PROCEDURES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and

More information

12/13/16. I. Liver transplantation for children and adults (initial or retransplantation) - must satisfy the following: A and B

12/13/16. I. Liver transplantation for children and adults (initial or retransplantation) - must satisfy the following: A and B Reference #: MC/T004 Page: 1 of 8 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan

More information

CIMZIA (certolizumab pegol)

CIMZIA (certolizumab pegol) CIMZIA (certolizumab pegol) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

12/12/17. I. Liver transplantation for children and adults (initial or retransplantation) - must satisfy the following: A and B

12/12/17. I. Liver transplantation for children and adults (initial or retransplantation) - must satisfy the following: A and B Reference #: MC/T004 Page: 1 of 8 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan

More information

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

PROTEOMIC TESTING FOR SYSTEMIC THERAPY IN NON-SMALL-CELL LUNG CANCER CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent

More information

BLINCYTO (blinatumomab)

BLINCYTO (blinatumomab) BLINCYTO (blinatumomab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and

More information

HEMATOPOIETIC CELL TRANSPLANTATION FOR EPITHELIAL OVARIAN CARCINOMA

HEMATOPOIETIC CELL TRANSPLANTATION FOR EPITHELIAL OVARIAN CARCINOMA CARCINOMA Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent

More information

DENOSUMAB (PROLIA & XGEVA )

DENOSUMAB (PROLIA & XGEVA ) DENOSUMAB (PROLIA & XGEVA ) UnitedHealthcare Oxford Clinical Policy Policy Number: PHARMACY 306.3 T2 Effective Date: July 2, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 CONDITIONS OF COVERAGE...

More information

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

GENETIC TESTING FOR KRAS, NRAS AND BRAF VARIANT ANALYSIS IN METASTATIC COLORECTAL CANCER METASTATIC COLORECTAL CANCER Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

[If no, skip to question 10.] Y N. 2. Does the member have a diagnosis of Paget s disease of bone? Y N. [If no, skip to question 4.

[If no, skip to question 10.] Y N. 2. Does the member have a diagnosis of Paget s disease of bone? Y N. [If no, skip to question 4. Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Zoledronic Acid (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

Approved by: Integrated Health Quality Management Subcommittee Effective Date: Department of Origin: Integrated Healthcare Services.

Approved by: Integrated Health Quality Management Subcommittee Effective Date: Department of Origin: Integrated Healthcare Services. Reference #: MC/L008 Page: 1 of 8 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS)

More information

Tusculum College. Benefit Summary. $25 Copay. $25 Copay. after Deductible. 20% after Deductible 20% after Deductible

Tusculum College. Benefit Summary. $25 Copay. $25 Copay. after Deductible. 20% after Deductible 20% after Deductible Benefit Plan Features: Annual Deductible Benefit Summary Your Cost In-Network Individual/Family $750/$1500 Annual Out-of-Pocket Maximum Individual/Family $3500/$7000 4th Quarter Carry-over Covered Services

More information

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

Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. HYDROXYPROGESTERONE THERAPY Makena (hydroxyprogesterone caproate injection) Hydroxyprogesterone caproate compound Hydroxyprogesterone caproate injection with benzyl benzoate and the preservative benzyl

More information

06/12/18. [Note: When orthognathic surgery is not a covered benefit, it is non-covered for any diagnosis, including sleep apnea.]

06/12/18. [Note: When orthognathic surgery is not a covered benefit, it is non-covered for any diagnosis, including sleep apnea.] Reference #: MC/B002 Page: 1 of 5 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS)

More information

TREATMENTS FOR GAUCHER DISEASE

TREATMENTS FOR GAUCHER DISEASE TREATMENTS FOR GAUCHER DISEASE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

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

Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. XOLAIR (omalizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

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

Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. ERYTHROPOIESIS-STIMULATING AGENTS (ESAs) Epoetin alfa (Epogen, Procrit ) Darbepoetin alfa (Aranesp ) Methoxy polyethylene glycol (PEG) epoetin-beta (Mircera ) Non-Discrimination Statement and Multi-Language

More information

John J. Wolf, DO Family Medicine

John J. Wolf, DO Family Medicine John J. Wolf, DO Family Medicine Objectives: 1. Review incidence & Risk of Osteoporosis 2.Review indications for testing 3.Review current pharmacologic & Non pharmacologic Tx options 4.Understand & Utilize

More information

Tusculum College. Benefit Summary Option/Quote: 2. 30% after Deductible. $35 Copay. 30% after Deductible

Tusculum College. Benefit Summary Option/Quote: 2. 30% after Deductible. $35 Copay. 30% after Deductible Benefit Plan Features: Annual Deductible Effective Date: 4/1/2018 Network: S Benefit Summary Option/Quote: 2 Your Cost In-Network Individual/Family $1250/$2500 Annual Out-of-Pocket Maximum Tusculum College

More information

VYXEOS (daunorubicin and cytarabine)

VYXEOS (daunorubicin and cytarabine) VYXEOS (daunorubicin and cytarabine) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical

More information

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

Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. NUCALA (mepolizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

ACTEMRA (tocilizumab)

ACTEMRA (tocilizumab) ACTEMRA (tocilizumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

Horizon Scanning Technology Briefing. Zoledronic Acid (Aclasta) once yearly treatment for postmenopausal. National Horizon Scanning Centre

Horizon Scanning Technology Briefing. Zoledronic Acid (Aclasta) once yearly treatment for postmenopausal. National Horizon Scanning Centre Horizon Scanning Technology Briefing National Horizon Scanning Centre Zoledronic Acid (Aclasta) once yearly treatment for postmenopausal osteoporosis December 2006 This technology summary is based on information

More information

MOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES

MOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES MOLECULAR TESTING IN THE MANAGEMENT OF PULMONARY NODULES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services,

More information

3. Has bone specific alkaline phosphatase level increased OR does the member have symptoms related to active Paget s?

3. Has bone specific alkaline phosphatase level increased OR does the member have symptoms related to active Paget s? Pharmacy Prior Authorization AETA BETTER HEALTH VIRGIIA CCC PLUS and MEDALLIO/FAMIS 4.0 Zoledronic Acid (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

CONTINUOUS OR INTERMITTENT GLUCOSE MONITORING IN INTERSTITIAL FLUID

CONTINUOUS OR INTERMITTENT GLUCOSE MONITORING IN INTERSTITIAL FLUID FLUID Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs are dependent

More information

Clinical Policy: Denosumab (Prolia, Xgeva) Reference Number: CP.PHAR.58

Clinical Policy: Denosumab (Prolia, Xgeva) Reference Number: CP.PHAR.58 Clinical Policy: (Prolia, Xgeva) Reference Number: CP.PHAR.58 Effective Date: 03/11 Last Review Date: 08/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important

More information

INTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION

INTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION INTRAPERITONEAL CHEMOTHERAPY, CYTOREDUCTION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,

More information

BRINEURA (cerliponase alfa)

BRINEURA (cerliponase alfa) BRINEURA (cerliponase alfa) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

INTRAVITREAL IMPLANTS

INTRAVITREAL IMPLANTS INTRAVITREAL IMPLANTS Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs

More information

Pediatric Dental and Vision

Pediatric Dental and Vision Individual & Family Plans (IFP) and Small Business Group (SBG) Health Net of California, Inc. (Health Net) Pediatric Dental and Vision Andre Hamil Health Net When you purchase a Health Net PureCare HSP

More information

PERCUTANEOUS BALLOON KYPHOPLASTY, RADIOFREQUENCY KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION

PERCUTANEOUS BALLOON KYPHOPLASTY, RADIOFREQUENCY KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION KYPHOPLASTY, AND MECHANICAL VERTEBRAL AUGMENTATION Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures,

More information

APOKYN (apomorphine hydrochloride)

APOKYN (apomorphine hydrochloride) APOKYN (apomorphine hydrochloride) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

OSTEOPOROSIS MEDICINES

OSTEOPOROSIS MEDICINES Bone Basics 2010. NOF. All rights reserved. National Osteoporosis Foundation 1150 17th Street, NW, Suite 850 Washington, DC 20036 (800) 223-9994 www.nof.org OSTEOPOROSIS MEDICINES Although there is no

More information

MYLOTARG (gemtuzumab ozogamicin)

MYLOTARG (gemtuzumab ozogamicin) MYLOTARG (gemtuzumab ozogamicin) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

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: (Forteo) Reference Number: CP.PHAR.188 Effective Date: 11.15.17 Last Review Date: 02.19 Line of Business: Commercial* (Exchange Plans), HIM, Medicaid Coding Implications Revision Log See

More information

Name of Policy: Boniva (Ibandronate Sodium) Infusion

Name of Policy: Boniva (Ibandronate Sodium) Infusion Name of Policy: Boniva (Ibandronate Sodium) Infusion Policy #: 266 Latest Review Date: April 2010 Category: Pharmacology Policy Grade: Active Policy but no longer scheduled for regular literature reviews

More information

TYSABRI FOR CROHN S DISEASE

TYSABRI FOR CROHN S DISEASE TYSABRI FOR CROHN S DISEASE Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices

More information

03/13/18. PURPOSE: The intent of this criteria document is to ensure services are medically necessary.

03/13/18. PURPOSE: The intent of this criteria document is to ensure services are medically necessary. Reference #: MC/C007 Page 1 of 5 PRODUCT APPLICATION: PreferredOne Community Health Plan (PCHP) PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA

More information