STAT Bulletin
PO Box 15013 • Albany, New York 12212
August 2, 2010 Volume 8: Issue 19
To: All PCPs and Specialists
Contracts Affected: All Lines of Business
Pharmacy and Medical Guideline Updates
As a result of the annual guideline review performed by our Pharmacy & Therapeutics Committee, attached to this bulletin are Pharmacy and Medical Guideline updates effective September 1, 2010. They are:
• New guidelines • Guidelines with changes that will affect the review process • Guidelines with date and/or reference changes (review process not affected) • Auto-pay ICD-9 codes for medical injectable medications • Injectable medication reference guide
This information will be available for review and can be printed from our web site after August 1, 2010. Go to www.bsneny.com, select I’m a Provider > Tools and Resources > Pharmacy Services.
If you do not have access to the internet, paper copies are available upon request after August 1, 2010. Please contact Provider Service at 1-800-444-4552 or 1-518-220-5620.
Page 1 of 5 3760-A NENY 662.Pub CC 1624 A Division of HealthNow New York Inc. An Independent Licensee of the BlueCross BlueShield Association 662 New Guidelines Effective September 1, 2010
Prescription Policy Summary Affect Drug (see guidelines for specifics) Rx or Med An effort to allow timely review of medications that are new Abbreviated to the market and consistent review of third-tier managed Rx, Med Criteria classes and non-formulary medications
Covered for moderate to severe rheumatoid arthritis, alone Actemra® or with methotrexate, when there has been an inadequate Med response to a TNF-inhibitor Covered for advanced renal cell carcinoma when there has Afinitor® Rx been a treatment failure with Sutent or Nexavar first Covered for chronic lymphocytic leukemia; preauthorization Arzerra® not required for ICD-9 codes 204.1, 204.10, 204.11, Med 204.12; added to Abbreviated Criteria Policy Covered for cutaneous T-cell lymphoma after the use of at Istodax® Med least one systemic therapy first Covered for the treatment of acute angioedema attacks if Kalbitor® Cinryze or Berinert is not tolerated first, added to Hereditary Med Angioedema Policy Covered for peripheral mobilization of stem cells for autologous transplantation in patients diagnosed with Non- Mozobil® Med Hodgkin’s lymphoma or multiple myeloma where criteria outlined in policy are met Coverage for OfortaTM is provided when the use of IV OfortaTM Rx fludarabine is medically contraindicated Coverage of quantities over 20 tablets per 365 days require Samsca® Rx review Coverage is provided for hepatic encephalopathy and Xifaxan® Rx traveler’s diarrhea according to prescribing guidelines
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Guidelines With Changes That Will Impact the Review Process Effective September 1, 2010
Prescription Policy Update Affect Drug (See guidelines for specifics) Rx or Med Removed prior step therapy requirements for children and Antiemetic Agents hyperemesis gravidarum, Sancuso added to policy, quantity Rx limits on ondansetron solution in place Policy statement added regarding Avastin in pancreatic Avastin® Med cancer; deemed investigational and not medically necessary Covered in combination with irinotecan for EGFR- Erbitux® expressing metastatic colorectal cancer when patients are Med refractory to irinotecan-based chemotherapy alone Preferred agents are now Synvisc, Synvisc One, Euflexxa. A Hyaluronan trial with two preferred agents will be required for coverage Med Injections* consideration of Hyalgan, Supartz, Orthovisc once general criteria is met Incretin Mimetics Renamed from Byetta, Victoza added to policy Rx Intravenous Renamed from Reclast, Boniva IV added to policy, criteria Med Bisphosphonates changed for Reclast and created for Boniva Migraine Agents Sumavel Dosepro added to policy Rx Proton Pump Dexilant added to policy (Kapidex reference removed) Rx Inhibitors Added a Black Box Warning regarding malignancy and Remicade® lymphoma; pediatric indicated reference added for Crohn’s Med disease Added indication for non-small cell lung cancer after no Tarceva® progression with four cycles of platinum-based first line Rx therapy Torisel® Torisel will not be covered in combination with Afinitor Med Added indication for HER2 receptor positive metastatic Tykerb® Rx breast cancer in certain patients Covered for gout that is refractory to allopurinol or patients Uloric® Rx who cannot take allopurinol Urinary Agents Gelnique added to policy Rx
*Important Note: Viscosupplementation (Hyaluronan Injections) Benefit
Preauthorization for viscosupplementation therapy will be reviewed and approved through the Use Management Customer Advocate Unit effective September 1, 2010. A Customer Advocate Unit Preauthorization Form will be posted to the provider web site and should be used when requesting approval for the following: • Preferred Agents: Synvisc®, Synvisc One®, Euflexxa® • Non-preferred Agents: Hyalgan®, Orthovisc®, Supartz®
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Guidelines with Date and/or Reference Changes (review process not affected) o Antifungal Agents o Kuvan® o Selzentry® o Anti-Influenza o Multiple Sclerosis o Sprycel® Therapy Agents o Stadol® o Arcalyst® o Nexavar® o Sutent® o Celebrex® o Noxafil® o Tasigna® o Diflucan® 150mg o Nutritional o Temodar® o Fentanyl Supplement/Enteral o Vectibix® o Flector® Patch o Formulas o Zolinza® o Gleevec® o Osteoporosis o Zyvox® o Herceptin® Agents
Auto-Pay ICD-9 Codes for Medical Injectable Medications
Effective September 1, 2010, some medical injectable medications will automatically pay when billed with the following diagnoses.
Medication (J code) Auto-pay ICD-9 codes Arzerra® (J9999) 204.1, 204.10, 204.11, 204.12
153.0 - 153.9, 154.0, 154.1, 362.50, 362.52, 362.53, Avastin® (J9035) 362.54, 362.55, 362.02, 362.07, 362.35, 362.36, 364.42, 365.63
Rituxan® (J9310) 202.80 - 202.88
Lupron®, Lupron Depot®, Eligard® 185, 198.82, 259.1 (J1950, J9217, J9218)
IVIg (J1561, J1568, J1569, J1566, 446.1, 357.0 J1572, J1562, J1563, J1459)
Macugen®, Lucentis® (J2503, J2778) 362.50, 362.52, 362.53, 362.54, 362.55
Dacogen®, Vidaza® (J0894, J9025) 205.1, 238.72, 238.73, 238.75
333.6, 333.7, 333.71, 333.79, 333.81, 333.82, 333.83, 333.84, 333.89, 334.1, 340, 341, 341.0, 341.1, 341.2, Botox®, Myobloc®, Dysport® (J0585, 341.8, 341.9, 342.1, 343.0-343.9, 344.00-344.09, J0586, J0587) 344.1, 344.2, 344.4, 351.8, 378, 478.75, 530.0, 564.6, 565.0, 723.5, 854, 952
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Injectable Medication Reference Guide
The following list of injectable medications require preauthorization when administered by a health care professional.
Actemra®* J3590 Macugen® J2503 Actimmune® J9216 Mozobil®* J2562 Amevive® J0215 Myobloc® J0587 Arzerra®* J9999 Nplate® J2796 Avastin® J9035 Octogam® J1568 Berinert® J0598 Orencia® J0129 Boniva®* J1740 Orthovisc® J7324 Botox® J0585 Privigen® J1459 Cimzia® J0718 Reclast ® J3488 Cinryze® J0598 Remicade® J1745 Dacogen® J0894 Remodulin® J3285 Dysport® J0586 Rituxan® J9310 Eligard® J9217 Simponi® J3590 Erbitux® J9055 Soliris® J1300 Euflexxa® J7323 Stelara® J3590 Flebogamma® J1572 Supartz® J7321 Gammagard® J1569 Synagis® 90378 Gamunex® J1561 Synvisc® J7325 Herceptin® J9355 Synvisc One® J7325 Hyalgan® J7321 Torisel® J9330 Istodax®* J9999 Tysabri® J2323 IVIg Powder J1566 Vectibix® J9303 Kalbitor®* J3590 Vidaza® J9025 Lucentis® J2778 Vivaglobin® J1562 Lupron Depot® J1950 Xolair® J2357 Lupron® J9218
*Effective September 1, 2010
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