Effective December 3, 2020
Hematopoietic Cell Transplantation for Hodgkin Lymphoma, 8.01.29
Criteria updated
- Tandem autologous hematopoietic cell transplantation (HCT) medical necessity criteria have been removed
- Tandem autologous hematopoietic cell transplantation (HCT) is now considered investigational in patients with Hodgkin lymphoma
Miscellaneous Oncology Drugs, 5.01.540
New drugs added to policy
- Blincyto® (blinatumomab)
- Treatment of adults and children for B-cell precursor acute lymphoblastic leukemia (ALL) in first or second complete remission with minimal residual disease (MRD)
- Treatment of adults and children with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL)
- Leukine® (sargramostim)
- Treatment of acute myeloid leukemia after induction chemotherapy
- Mobilization and following transplant of autologous peripheral blood progenitor cells
- Myeloid reconstitution after (allogenic or autologous) bone marrow transplant
- Treatment for bone marrow transplant (allogenic or autologous) failure or engraftment delay
- Treatment for exposure to myelosuppressive doses of radiation (Hematopoietic Syndrome of Acute Radiation Syndrome)
Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517
New drugs added to policy
- Cyramza® (ramucirumab)
- Treatment of advanced or metastatic gastric or gastro-esophageal junction (GEJ) cancer that has continued to grow while on or after prior fluoropyrimidine- or platinum- containing chemotherapy when used as a single agent or with paclitaxel
- Treatment of metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) gene changes (exon 19 or exon 21) as first-line therapy when used with erlotinib
- Treatment of metastatic non-small cell lung cancer (NSCLC) that has continued to grow while on or after platinum-based chemotherapy when used with docetaxel
- Treatment of metastatic colorectal cancer (mCRC) that has continued to grow while on or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine when used with a FOLFIRI chemotherapy combination
- Treatment of hepatocellular carcinoma (HCC) in patients who have an elevated alpha fetoprotein and have been treated with sorafenib when used as a single agent
Effective October 2, 2020
Miscellaneous Oncology Drugs, 5.01.540
New drugs added to policy
- Kyprolis® (carfilzomib)
- Treatment of multiple myeloma
- Velcade® (bortezomib)
- Treatment of multiple myeloma and mantle cell lymphoma
Pharmacotherapy of Arthropathies, 5.01.550
Site of service review added
- Avsola™ (infliximab-axxq)
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563
Site of service review added
- Avsola™ (infliximab-axxq)
Pharmacologic Treatment of Infertility, 5.01.610
New policy
The following drugs have been added and may be considered medically necessary when criteria are met:
- Brand Chorionic Gonadotropin
- Bravelle® (urofollitropin)
- Follistim® AQ (follitropin beta)
- Pregnyl® (chorionic gonadotropin)
Prostate Cancer Targeted Therapies, 5.01.544
New drugs added to policy
- Jevtana® (cabazitaxel)
- Xofigo® (radium Ra 223 dichloride)
Rituximab Non-Oncologic and Miscellaneous Uses, 5.01.556
Site of service review added
- Ruxience™ (rituximab-pvvr)
Effective September 4, 2020
Folate Antimetabolites, 5.01.617
New policy
The following drugs have been added and may be considered medically necessary when criteria are met:
- Alimta® (pemetrexed)
- In combination with Keytruda® (pembrolizumab) and platinum chemotherapy for the initial treatment of metastatic non-squamous non-small cell lung cancer (NSCLC)
- In combination with cisplatin for the initial treatment of locally advanced or metastatic, non-squamous NSCLC
- As a single agent for the maintenance treatment of locally advanced or metastatic, non-squamous NSCLC in patients whose disease has not progressed after four cycles of platinum-based first-line chemotherapy
- As a single agent for the treatment of recurrent, metastatic non-squamous, NSCLC after prior chemotherapy
- Initial treatment, in combination with cisplatin, of malignant pleural mesothelioma in patients whose disease can’t be surgically treated or who are not candidates for curative surgery
- Folotyn® (pralatrexate)
- Treatment of relapsed or refractory peripheral T-cell lymphoma (PTCL)
Pharmacologic Treatment of Gout, 5.01.616
New policy
The following drug has been added and may be considered medically necessary when criteria are met:
- Krystexxa® (pegloticase)
- Treatment of chronic gout in patients age 18 and older