Effective January 1, 2016, new precertification
requirements will apply to our commercial and Medicare Advantage HMO and PPO
members for the seven medical benefit drugs listed below:
- Adagen® (pegademase bovine)
- Blincyto® (blinatumomab)
- Cyramza® (ramucirumab)
- Imlygic? (talimogene laherparepvec)
- Kanuma? (sebelipase alfa)*
- Lemtrada® (alemtuzumab)
- mepolizumab*
These changes will be reflected in an updated precertification requirement
list, which will be posted to our
website in December, prior to these changes going into
effect.
In addition, Notifications for new medical policies for Adagen (pegademase
bovine) and Cyramza (ramucirumab) will be available in December.
Coverage for off-label use
The medical necessity criteria for these drugs are based on the U.S. Food
and Drug Administration (FDA)-labeled indications. Coverage for off-label use
of these drugs may be provided in accordance with the following policies:
- Commercial: #08.00.15c: Off-label Coverage for
Prescription Drugs and Biologics
- Medicare Advantage: #MA08.012: Off-label Coverage for
Prescription Drugs and/or Biologics
To view these policies, visit our Medical Policy Portal. Select
Accept and Go to Medical Policy Online, and then select
Commercial or Medicare Advantage depending on the version of
the policy you?d like to view.
Look for more information about the availability of the new precertification
requirement list in the December 2015 edition of Partners in Health
UpdateSM.
*Pending approval from the U.S. Food and Drug
Administration