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Prior Review to be Required for Synagis® effective 7/1/2010

Effective July 1, 2010, prior review is required for coverage of respiratory syncytial virus (RSV) prophylaxis with palivizumab (Synagis).

Criteria for coverage of Synagis are outlined in a new medical policy that is available online in the "Medical Policy" section of bcbsnc.com.

When RSV Prophylaxis is Covered

Monthly administration of immune prophylaxis for respiratory syncytial virus during the RSV season with palivizumab may be considered medically necessary in the following infants and children in accordance with the current (2009) guidelines from the American Academy of Pediatrics.

  1. Infants with chronic lung disease (CLD, [formerly known as bronchopulmonary dysplasia]). Infants and children younger than 24 months of age who receive medical therapy (supplemental oxygen, bronchodilator, diuretic or chronic corticosteroid therapy) for chronic lung disease within 6 months before the start of the RSV season, up to a maximum of 5 monthly doses.
  2. Infants born before 32 weeks' gestation (31 weeks, 6 days or less). Infants in this category may benefit from RSV prophylaxis, up to a maximum of 5 monthly doses, even if they do not have CLD. For these infants, major risk factors to consider include gestational age and chronologic age at the start of the RSV season.
    • Infants born at 28 weeks gestation or earlier (up to and including 28 weeks, 6 days) may benefit from prophylaxis during the RSV season, whenever that occurs during the first 12 months of life.

      OR

    • Infants born at 29 to 32 weeks gestation may benefit most from prophylaxis if younger than 6 months of age at the start of the RSV season. In this setting, 32 weeks' gestation refers to an infant born before the 32nd week of gestation (31 weeks, 6 days or less).
  3. Infants born at 32 to less than 35 weeks' gestation (defined as 32 weeks, 0 days through 34 weeks, 6 days). Infants younger than 3 months of age at the start of or born during RSV season who are likely to have an increased risk of exposure to RSV when at least one of the following risk factors is present:
    • Infant attends child care, defined as a home or facility where care is provided for any number of infants or young toddlers in the child care facility; or
    • Infant has a sibling younger than 5 years of age.
    • Infants in this gestational age category should receive prophylaxis only until they reach 3 months of age, maximum of 3 monthly doses.
  4. Infants with congenital abnormalities of the airway or neuromuscular disease. Infants born before 35 weeks of gestation who have either congenital abnormalities of the airway or a neuromuscular condition that compromises handling of respiratory secretions, during the first year of life up to a maximum of 5 monthly doses.
  5. Infants and children with congenital heart disease. Children who are 24 months of age or younger with hemodynamically significant cyanotic or acyanotic congenital heart disease may benefit from palivizumab prophylaxis. Decisions regarding prophylaxis with palivizumab in children with congenital heart disease should be made on the basis of the degree of physiologic cardiovascular compromise. Children younger than 24 months of age with congenital heart disease who are most likely to benefit from immunoprophylaxis include:
    • Infants who are receiving medication to control congestive heart failure;
    • Infants with moderate to severe pulmonary hypertension;
    • Infants with cyanotic heart disease

After surgical procedures that use cardiopulmonary bypass, for children who still require prophylaxis, a postoperative dose of palivizumab may be considered appropriate as soon as the patient is medically stable.

When RSV Prophylaxis is Not Covered

Immunoprophylaxis for respiratory syncytial virus is considered not medically necessary for

  • Infants and children with hemodynamically insignificant heart disease (e.g., secundum atria septal defect, small ventricular septal defect, pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation of the aorta, and patent ductus arteriosus);
  • Infants with lesions adequately corrected by surgery, unless they continue to require medication for congestive heart failure;
  • Infants with mild cardiomyopathy who are not receiving medical therapy for the condition.

Other indications for immune prophylaxis for respiratory syncytial virus are considered investigational including, but not limited to, immunocompromised children; patients with cystic fibrosis; for use in controlling outbreaks of health care-associated disease.

If approved, Synagis is covered under BCBSNC's medical benefits.

For a complete listing of prescription medications that require prior review, please visit http://www.bcbsnc.com/content/providers/ppa/prescriptions.htm.

Change in Coverage for Angiotensin Receptor Blockers (ARBs) Effective 7/1/2010

Effective July 1, 2010, Blue Cross and Blue Shield of North Carolina (BCBSNC) is changing the administrative process regarding coverage of the nonpreferred angiotensin receptor blockers (ARBs) identified below. Going forward, reimbursement of these drugs will be considered only after a member's physician certifies in writing to BCBSNC that the member has previously used at least one preferred ARB and such drug was ineffective in treating the condition or was detrimental to the member's health.
ANGIOTENSIN RECEPTOR BLOCKERS (ARBs)
NONPREFERRED MEDICATIONS:
  • Atacand® and Atacand HCT®
  • Avapro® and Avalide®
  • Benicar® and Benicar HCT®
  • Teveten® and Teveten HCT®
ANGIOTENSIN RECEPTOR BLOCKERS (ARBs)
PREFERRED MEDICATIONS
  • losartan (generic or brand Cozaar®) or losartan/HCTZ (generic or brand Hyzaar®)
  • Diovan® or Diovan HCT®
  • Micardis® or Micardis HCT®

1 Only the nonpreferred drugs listed are subject to physician certification requirement.

For a complete listing of prescription medications that require prior review, please visit http://www.bcbsnc.com/content/providers/ppa/prescriptions.htm.

Prior Review to be Required for Stelara™ and Actemra® Effective 7/1/2010

Effective July 1, 2010, prior review is required for coverage of ustekinumab (Stelara) and tocilizumab (Actemra).

Criteria for coverage of Stelara and Actemra will be outlined in new medical policies that will be available online in the "Medical Policy" section of bcbsnc.com.

When Stelara will be covered

Ustekinumab (Stelara) may be considered medically necessary for the treatment of moderate to severe plaque psoriasis in patients who are 18 years of age or older; and have already been treated with phototherapy (i.e., PUVA or broadband or narrowband UVB) unless the patient is not a candidate for phototherapy or phototherapy is not available to the patient; and have already been treated with or are not a candidate for any other systemic treatments such as methotrexate (oral or IM), cyclosporin, and acitretin (Soriatane®).

When Actemra will be covered

Tocilizumab (Actemra®) may be medically necessary for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies.
Tocilizumab (Actemra) should NOT be used in patients with an absolute neutrophil count (ANC) below 2000/mm3, platelet count below 100,000/mm3, or who have ALT or AST above 1.5 times the upper limit of normal. Tocilizumab (Actemra®) should not be administered in patients with an active infection, including localized infections.

If approved, Stelara and Actemra are covered under BCBSNC's medical benefits.

For a complete listing of prescription medications that require prior review, please visit http://www.bcbsnc.com/content/providers/ppa/prescriptions.htm.