Medical Policy Updates

Notification of Policy Revisions Effective December 31, 2019 (Posted October 29, 2019)

Medical Policy Revision
Erythropoiesis-Stimulating Agents (ESAs) “Notification” Updated “When Covered” with the following statement: “Epogen and Procrit may be medically necessary when the criteria listed above for epoetin alfa is met, and when the patient has tried and failed, or is intolerant to, or has a clinical contraindication to Retacrit.” Medical Director review 10/2019. Notification given 10/29/2019 for effective date 12/31/2019
Trastuzumab "Notification" Under “When Covered,” added Ogivri (trastuzumab-dkst), Herzuma (trastuzumab-pkrb), Ontruzant (trastuzumab-dttb), and Trazimera (trastuzumab-qyyp) biosimilars to Herceptin (trastuzumab) for the treatment of HER2 overexpressing breast cancer and HER2 overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma. Added HCPCS codes Q5112, Q5113, Q5114, and Q5116 to Billing/Coding section.  References added. Medical Director review 10/2019. Notification given 10/29/2019 for effective date 12/31/2019