Medical Policy and Coding Updates June 2023

  • Updates for both non-individual and individual plans

  • Effective September 1, 2023

    Intraarticular Corticosteroids, 5.01.633  PBC | Premera HMO
    New policy
    Drug added

    • Zilretta® (triamcinolone acetonide extended-release injectable suspension) Intra-articular
      • Added as medically necessary for moderate to severe osteoarthritis pain of the knee in adults and may be approved once per knee per lifetime
      • Considered investigational for all other indications

    Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures), 7.01.14  PBC | Premera HMO
    New policy
    Maze or modified maze procedure
    Medical necessity criteria added

    • For the treatment of atrial fibrillation or flutter when performed on a non-beating heart during cardiopulmonary bypass

    Stand-alone minimally invasive, off-pump maze procedures
    Investigational criteria added

    • For the treatment of atrial fibrillation and flutter, including when done via mini-thoracotomy

    Hybrid ablation
    Investigational criteria added

    • For the treatment of atrial fibrillation and flutter

    Effective August 4, 2023

    Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
    Miscellaneous intramuscular/intravenous/subcutaneous agents
    Drug added

    • Xgeva® (denosumab)
      • For the prevention of skeletal-related events in individuals with bone metastases from solid tumors
      • For the prevention of skeletal-related events in individuals with multiple myeloma

    Effective July 6, 2023

    Pharmacologic Treatment of Clostridium Difficile, 5.01.631  PBC | Premera HMO
    New policy
    Drugs added

    • Rebyota™ (fecal microbiota, live-jslm)
    • Zinplava™ (bezlotoxumab)
      • For the treatment of Clostridioides difficile infection in individuals aged 18 years and older

    New medical policies
    Effective June 1, 2023

    Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.506  PBC | Premera HMO
    Policy renumbered
    This policy replaces Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.11

    Continuous Passive Motion in the Home Setting, 1.01.540  PBC | Premera HMO
    Policy renumbered
    This policy replaces Continuous Passive Motion in the Home Setting, 1.01.10

    Cooling Devices Used in the Outpatient Setting, 1.01.538  PBC | Premera HMO
    Policy renumbered
    This policy replaces Cooling Devices Used in the Outpatient Setting, 1.01.26

    Revised medical policies
    Effective June 1, 2023

    No updates this month.

    New pharmacy policies
    Effective June 1, 2023

    Adstiladrin® (nadofaragene firadenovec-vncg), 5.01.632  PBC | Premera HMO
    New policy
    Drug added

    • Adstiladrin® (nadofaragene firadenovec-vncg) Intravesical
      • Added medical necessity criteria for treatment of non-muscle invasive bladder cancer (NMIBC) with carcinoma in situ (CIS)

    Gene Therapies for Cerebral Adrenoleukodystrophy, 5.01.634  PBC | Premera HMO
    New policy
    Drug added

    • Skysona® (elivaldogene autotemcel) IV
      • Added medical necessary criteria for treatment of adrenoleukodystrophy
      • Use is limited to a one-time infusion

    Revised pharmacy policies
    Effective June 1, 2023

    Amyotrophic Lateral Sclerosis (ALS) Medications, 5.01.578  PBC | Premera HMO
    Drug added

    • Qalsody™ (tofersen) Intrathecal
      • Added medical necessity criteria for treatment of amyotrophic lateral sclerosis (ALS)
      • Considered investigational for other conditions

    Antibody-Drug Conjugates, 5.01.582  PBC | Premera HMO
    Drug added

    • Padcev® (enfortumab vedotin-ejfv) IV
      • Added medical necessity criteria for treatment of locally advanced or metastatic urothelial cancer (mUC) in adults
      • Considered investigational for all other indications

    BRAF and MEK Inhibitors, 5.01.589  PBC | Premera HMO
    Combination therapy for other indications
    Medical necessary criteria updated
    Added indication for treatment of low-grade glioma (LGG) with BRAF V600E mutations in individuals aged 1 year and older

    • Tafinlar® (dabrafenib) in combination with Mekinist® (trametinib)

    Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
    PD-1 inhibitors
    Drug added

    • ZynyzTM (retifanlimab-dlwr) IV
      • Added medical necessity criteria for the treatment of metastatic or recurrent, locally advanced Merkel cell carcinoma (MCC) who have not received a prior systemic therapy

    Medical necessity criteria updated
    Added indications for treatment of stage IB, II or IIIA non-small cell lung cancer (NSCLC) or locally advanced or metastatic urothelial carcinoma (la/mUC)

    • Keytruda® (pembrolizumab)

    Medical necessity criteria updated
    Treatment of unresectable or metastatic alveolar soft part sarcoma (ASPS) in individuals aged 2 years and older

    • Tecentriq® (atezolizumab)

    Herceptin® (trastuzumab) and Other HER2 Inhibitors, 5.01.514  PBC | Premera HMO
    Oral drugs
    Medical necessity criteria updated
    Added indication for the treatment of RAS wild-type, HER2-positive, unresectable or metastatic colorectal cancer in adults

    • Tukysa® (tucatinib)

    Hetlioz® (tasimelteon), 5.01.552  PBC | Premera HMO
    MT1 and MT2 antagonists
    Drug added

    • Generic tasimelteon capsules
      • Added medical necessity criteria for treatment of non-24-hour sleep-wake disorder in individuals aged 18 years or older
      • Quantity limit is 20 mg per day
      • Considered investigational for all other indications

    Medical necessity criteria updated
    Added criterion requiring documented trial and failure or intolerance to generic tasimelteon

    • Hetlioz® (tasimelteon) capsules

    Migraine and Cluster Headache Medications, 5.01.503  PBC | Premera HMO
    Brand name triptans
    Drug added

    • RizaFilm® (rizatriptan; oral film)
      • Considered medically necessary for treatment of acute migraine and cluster headaches

    Quantity limit added
    Added 18 oral films per 30 days

    CGRP Inhibitors
    Drug added

    • Zavzpret™ (zavegepant)
      • Considered medically necessary for the treatment of migraine with or without aura in individuals aged 18 years and older
      • Use is not concurrent with Nurtec® ODT (rimegepant) or Ubrelvy® (ubrogepant)

    Medical necessity criteria updated
    Added Zavzpret™ (zavegepant) to the list of agents for which concomitant use is not allowed

    • Nurtec® ODT (rimegepant)
    • Ubrelvy® (ubrogepant)

    Monoclonal Antibodies for the Treatment of Lymphoma, 2.03.502  PBC | Premera HMO
    Polivy™ (polatuzumab vedotin-piiq)
    Medical necessity criteria updated
    Added indication for use in combination with a rituximab product, cyclophosphamide, doxorubicin, and prednisone (R-CHP)

    • Polivy™ (polatuzumab vedotin-piiq)

    Pharmacotherapy of Arthropathies, 5.01.550  PBC | Premera HMO
    First-line IL-6 inhibitors
    Drug added

    • Kevzara® (sarilumab) SC
      • Added medical necessity criteria for treatment of polymyalgia rheumatic in adults

    Second-line Janus kinase inhibitors
    Note added
    Use for treatment of alopecia is considered cosmetic

    • Olumiant® (baricitinib) oral

    Pharmacotherapy of Multiple Sclerosis, 5.01.565  PBC | Premera HMO
    Relapsing multiple sclerosis (RMS)
    Drug added

    • Generic teriflunomide oral
      • Added medical necessity criteria for treatment of RMS

    Medical necessity criteria updated
    Added criterion requiring documented trial and failure or intolerance to generic teriflunomide

    • Aubagio® (teriflunomide) oral

    Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders, 5.01.620  PBC | Premera HMO
    Medical necessity criteria updated
    Added indication for treatment of retinopathy prematurity (ROP)

    • Eylea® (aflibercept)

    Effective June 1, 2023

    No updates this month

    Effective June 1, 2023

    Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.11
    This policy is replaced with Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses, 1.01.506

    Continuous Passive Motion in the Home Setting, 1.01.10
    This policy is replaced with Continuous Passive Motion in the Home Setting, 1.01.538

    Cooling Devices Used in the Outpatient Setting, 1.01.26
    This policy is replaced with Cooling Devices Used in the Outpatient Setting, 1.01.540

    Added codes
    Effective June 1, 2023

    Intravenous Iron Replacement products, 5.01.630  PBC | Premera HMO

    Now requires review for medical necessity and prior authorization.

    J1437, J1439, Q0138, Q0139

    Revised codes
    Effective June 1, 2023

    No updates this month

    Removed codes
    Effective June 1, 2023

    No updates this month

  • Updates for non-individual plans only

  • No updates this month
    No updates this month

  • Updates for individual plans only

  • No updates this month

     

    No updates this month

     

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