STAT Bulletin

PO Box 80 • Buffalo, New York 14240-0080

May 28, 2010 Volume 16: Issue 14

To: All PCPs and Specialists

Contracts Affected: All Lines of Business

Pharmacy and Medical Guideline Updates

As of July 1, 2010, the attached and Medical Guideline updates will become effective. These updates are a result of the annual guideline review performed by our Pharmacy & Therapeutics Committee.

The updated Drug Therapy Guidelines will be available for review online as of June 1, 2010. Go to www.bcbswny.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, as of June 1, by calling Provider Service at 1-800-950-0051 or 1-716-884-3461.

New Guidelines

Prescription Policy Summary Affect Drug (see guidelines for details) Rx or Med Review for diagnosis of myelodysplastic syndrome (MDS) and previous treatment for MDS; review for diagnosis of Revlimid® Rx multiple myeloma, concurrent dexamethasone, absolute neutrophil count Review for previous tumor necrosis factor therapy and Simponi® diagnosis of psoriatic arthritis, ankylosing spondylitis or Rx, Med rheumatoid arthritis Review for diagnosis of plaque psoriasis and previous Stelara™ Med therapies

Testim® Will require trial with preferred alternative Androgel® first Rx

Review for diagnosis of relapsed or surgically unresectable Votrient™ Rx stage IV advanced renal cell carcinoma

Page 1 of 5 3367-B WNY C9013.Pub CC 1624 A Division of HealthNow New York Inc. An Independent Licensee of the BlueCross BlueShield Association C9013 Guidelines with changes affecting the review process

Policy Update Affect Rx Prescription Drug (see guidelines for specifics) or Med Actimmune® Begin to enforce policy Rx, Med New indication for candidiasis of the esophagus and Antifungal Agents Rx oropharyngeal candidiasis added for Sporanox® Anti-influenza H1N1 information added Rx Appetite Suppressants and Change in renewal criteria Rx Weight Loss Agents Avastin® New diagnoses added Med Benign Prostatic Coverage duration extended; finasteride added Rx Hyperplasia Therapy Botulinum toxins Full policy update Med Celebrex® Coverage duration extended; 100mg BID dosing addressed Rx Cimzia® Full policy update Rx, Med Colony Stimulating Step Therapy requirement removed for coverage of Neulasta® Rx Factors Enbrel® Juvenile idiopathic arthritis addressed; psoriasis criteria update Rx Erbitux® Begin to enforce policy; Full policy update Med Erectile Dysfunction Language added to address daily therapy Rx Agents Fentanyl® Onsolis® added to policy Rx Flector® Patch Clarification regarding previous oral NSAID use Rx New indication for glucocorticoid induced osteoporosis; updated Forteo® Rx coverage criteria Gleevec® Expanded coverage to allow for more diagnoses Rx Gonadotropin- Releasing Endometriosis diagnosis now requires prior authorization Rx, Med Hormone Agonist Growth Stimulating Full policy update with new preferred agents Rx Drugs Hereditary Cinryze® criteria renamed Hereditary Angioedema (HAE) Agents Angioedema (HAE) Med with the addition of Berinert® Agents Hepatitis C Anti- Full policy update Rx Virals Herceptin® Begin to enforce policy Med Immune Thrombocytopenia Begin to enforce policy Rx, Med Purpura (ITP) Agents Intravenous Immune Globulin Full policy update Med (IVIg) Therapy Iressa™ Updated non-small cell lung coverage criteria Rx

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Policy Update Affect Rx Prescription Drug (see guidelines for specifics) or Med Leukotriene Receptor Updated allergic rhinitis coverage criteria Rx Antagonists Migraine Agents Addressed nasal spray formulations Rx Multiple Sclerosis Tysabri® removed from Multiple Sclerosis Agents policy. Policy Rx Agents for Tysabri® created Myelodysplastic No prior authorization required for five forms of MDS. See auto- Syndrome Med pay chart below. (MDS) Therapy Orencia® Added juvenile idiopathic arthritis indication Med Pulmonary Arterial Adcirca® added; Remodulin® moved to its own policy Rx Hypertension Agents Regranex® Language added re: neoplasms; Black Box Warning added Rx Relistor® Change renewal period of approval to 6 months Rx Remodulin® Begin to enforce policy Med Name changed from Tekturna® to Renin Inhibitors; Valturna® Renin Inhibitors Rx added Restasis® Optometrists removed from automatic approval process Rx Sedative Hypnotics Edluar® and ZolpiMist™ added Rx Soliris® Begin to enforce policy Med Sutent® Allow as first line for renal cell carcinoma Rx Synagis® 2009 American Academy of Pediatrics guideline adopted Med Expand coverage to include unresectable advanced metastatic Temodar® Rx melanoma Torisel® Begin to enforce policy Med Rheumatoid Arthritis indication added; Policy separated from Tysabri® Med Multiple Sclerosis Agent Policy Vascular Endothelial Macugen® criteria renamed Vascular Endothelial Growth Factor Growth Factor Med Inhibitors to now include Avastin®, Macugen® and Lucentis® Inhibitors Vectibix® Begin to enforce policy Med Wakefulness Nuvigil® added Rx Promoting Agents

Page 3 of 5 Guidelines with date and/or reference changes; review process not affected

Anti-emetic Anti- Recombinant Inspra® Tasigna® vertigo Agents Erythropoietin Agents Antipsoriatic Intranasal Steroids Rituxan® Torisel® Therapy Apokyn® Kineret® Selzentry® Tykerb®

Arcalyst® Kuvan® Sensipar® Urinary Agents

Byetta® Nexavar® Somavert® Voltaren® Gel Diflucan® 150mg Noxafil® Sprycel® Xenazine™ Tablets Nutritional Humira® Supplements/ Stadol ® Xolair® Enteral Formulas Hyaluronan Osteoporosis Symlin® Zolinza® Injections Agents Injectable Fertility Proton Pump Tarceva® Zyvox® Inhibitors (PPIs)

Auto-Pay ICD-9 Codes for Medical Injectable Medications Effective July 1, 2010, some medical injectable medications will automatically pay when billed with the following diagnoses:

Medication (J-code) Auto-Pay ICD-9 Codes 153.0 - 153.9, 154.0, 154.1, 362.50, 362.52, Avastin® (J9035) 362.53, 362.54, 362.55 Macugen®, Lucentis® 362.50, 362.52, 362.53, 362.54, 362.55 (J2503, J2778)

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) Dacogen®, Vidaza® 205.1, 238.72, 238.73, 238.75 (J0894, J9025) 333.6, 333.7, 333.71, 333.79, 333.81, 333.82, 333.83, 333.84, 333.89, 334.1, 340, 341, 341.0, Botox®, Myobloc®, Dysport® 341.1, 341.2, 341.8, 341.9, 342.1, 343.0-343.9, (J0585, J0586, J0587) 344.1, 344.2, 344.4, 351.8, 378, 478.75, 530.0, 564.6, 565.0, 723.5, 854, 952

Page 4 of 5 Injectable Reference Guide As a reference guide, the following list of injectable medications require preauthorization when administered by a professional.

Actimmune® * J9216 Nplate® J2796 Amevive® J0215 Octogam® J1568 Avastin® J9035 Orencia® J0129 Berinert® * J0598 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 IVIg Powder J1566 Tysabri® J2323 Lucentis® J2778 Vectibix® * J9303 Lupron Depot® J1950 Vidaza® J9025 Lupron® J9218 Vivaglobin® J1562

* Effective July 1, 2010

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