Medical Policy Updates

Table Of Contents

Notification of Policy Revisions Effective February 1 , 2013 (Posted December 1, 2012)

Medical Policy Revision
Abatacept (Orencia®) "Notification" "When Covered" section modified to add medical necessity criterion "The patient has failed to respond adequately or is intolerant to Remicade® (infliximab)." Notice 12/1/12, effective 2/1/13.
Rituximab for the Treatment of Rheumatoid Arthritis "Notification" "When Covered" section modified to revise statement "The patient has failed to respond adequately to at least one Tumor Necrosis Factor (TNF) inhibiting drug or is intolerant to all TNF-inhibiting drugs (i.e., Remicade® (infliximab), Enbrel® (etanercept), or Humira® (adalimumab);" to "The patient has failed to respond adequately or is intolerant to Remicade® (infliximab)." Notice 12/1/12, effective 2/1/13.
Tocilizumab (Actemra) "Notification" "When Covered" section modified to revise medical necessity criteria from "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." to "Tocilizumab (Actemra®) may be medically necessary for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have failed to respond adequately or are intolerant to Remicade® (infliximab)."; and from "Tocilizumab (Actemra®) may be medically necessary for the treatment of patients 2 years of age and older with active systemic juvenile idiopathic arthritis (sJIA)." to "Tocilizumab (Actemra®) may be medically necessary for the treatment of patients between 2 and 6 years of age with active systemic juvenile idiopathic arthritis (sJIA). Tocilizumab (Actemra®) may be medically necessary for the treatment of patients 6 years of age and older with active systemic juvenile idiopathic arthritis (sJIA) who have failed to respond adequately or are intolerant to Remicade® (infliximab)." Notice 12/1/12, effective 2/1/13.