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Each week, the AUA publishes weekly updates on the latest insurance issues pertaining to urology. This week, the following plans have released new or amended prior authorization requirements: CarePlus, Minnesota Medicaid, Providence Health Plan, Total Healthcare, Uniform Medical Plan, and UnitedHealthcare (UHC). Additionally, these plans have updated their medical policies as follows: BlueAdvantage Administrators of Arkansas (Nerve Graft with Radical Prostatectomy), BCBS Kansas City Missouri (Biofeedback as a Treatment of Urinary Incontinence in Adults, Yonsa, Percutaneous Tibial Nerve Stimulation [PTNS], Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia [BPH]), BCBS Michigan (Yonsa/Zytiga), BCBS Mississippi (Biofeedback, PTNS, Gene Expression Profiling for Prostate Cancer, Transurethral Water Vapor Thermal Therapy for BPH), BCBS North Dakota (Biofeedback), BCBS South Carolina (Biofeedback), CGS Administrators (Decipher Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease, Next-Generation Sequencing for Solid Tumors, Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease), eviCore Healthcare (Decipher Prostate Cancer Classifier), Health Alliance Plan of Michigan (Lupron/Leuprolide Acetate), Highmark Inc. (Yonsa/Zytiga), Humana (Urinary Incontinence Treatments), Kaiser Permanente (BPH Treatments), Nebraska Blue (Adjustable Balloon Continence Devices), QualChoice (Nubeqa), and Tufts Health Plan (Prolia, Xgeva). Please see below for further information about each update.

BlueAdvantage Administrators of Arkansas

Nerve Graft with Radical Prostatectomy: This policy has been reviewed and updated to reflect the changes in coverage regarding unilateral or bilateral nerve grafts. This procedure is considered investigational.

Read the complete update.

BCBS Kansas City Missouri

Biofeedback as a Treatment of Urinary Incontinence in Adults: This policy has been reviewed and updated with the following additions to coding:

• 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient
• 90913 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)
  

Yonsa: BCBS Kansas City Missouri has published a new policy regarding the prostate cancer drug Yonsa. Yonsa may be considered medically necessary when criteria are met.

• Prostate Cancer – metastatic, Castration-Resistant (mCRPC). Approve for 1 year if Yonsa is used in combination with methylprednisolone.

Percutaneous Tibial Nerve Stimulation (PTNS): This policy has been reviewed and updated with the following additions to HCPCS coding:

• 0578T - Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve.
• 0588T - Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve.
• 0589T - Electronic analysis with simple programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 1-3 parameters.
• 0890T - Electronic analysis with complex programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 4 or more parameters.

Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia: This policy has been reviewed and updated with the following CPT code addition:

• 0582T - Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance

BCBS Michigan

Prolia, Xgeva: The BCBS Michigan medical policy for the drugs Prolia and Xgeva has been updates with the following changes to criteria:

Coverage of the requested drug is provided when all the following are met:

• For the prevention of skeletal-related events in patients with multiple myeloma or with bone metastases from solid tumors (Xgeva only) when the below criteria are met:

  • Documentation that at least one IV bisphosphonate has been ineffective, not tolerated or contraindicated, OR

  • National Comprehensive Cancer Network (NCCN) supported category 1 preferred agent for prevention of skeletal related events in patients with bone metastases for the specific oncological diagnosis AND

  • Patient will supplement with calcium 1000 mg daily and at least 400 IU vitamin D daily OR

• For the treatment of adults and skeletally mature adolescents with giant cell tumor of bone (Xgeva only) when these criteria have been met:

  • Documentation of confirmed giant cell tumor of bone and radiologic evidence of measurable disease (via CT scan or MRI)

  • Bone is unresectable or surgical resection is likely to result in severe morbidity

  • Patient will supplement with calcium 1000 mg daily and at least 400 IU vitamin D daily OR

• For the treatment of hypercalcemia of malignancy (HCM) refractory to bisphosphonate therapy (Xgeva only)

  • Diagnosis of hypercalcemia secondary to a malignancy (including hematologic malignancies)

  • Albumin corrected serum calcium (CSC) ≥ 12 mg/dL (3.0 mmol/L)

  • Documentation that at least one IV bisphosphonate has been ineffective, not tolerated or contraindicated OR

• For the treatment of osteoporosis (Prolia only) when all of the criteria below are met:

  • BMD T-score at or below -2.5 at the lumbar spine or total hip

  • At least one bisphosphonate (if patient has intolerance to oral administration, IV administration will be required) is not effective after at least a 24 month treatment period based on objective documentation except if:

    • Bisphosphonates (oral and intravenous formulations) are contraindicated

  • Patient will supplement with calcium 1000 mg daily and at least 400 IU vitamin D daily

  • Will NOT be used in combination with any anabolic bone modifying agent OR

• To increase bone mass in men at high risk for fracture receiving androgen deprivation therapy for nonmetastatic prostate cancer OR women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for nonmetastatic breast cancer when all of the criteria below are met (Prolia only):

  • When the 10-year probability of hip fracture is ≥ 3% or the 10-year probability of a major osteoporosis-related fracture is ≥ 20%.

  • At least one bisphosphonate (if patient has intolerance to oral administration, IV administration will be required) is not effective after at least a 24 month treatment period based on objective documentation except if:

    • Bisphosphonates (oral and intravenous formulations) are contraindicated

  • Patient will supplement with calcium 1000 mg daily and at least 400 IU vitamin D daily

• Trial and failure of the preferred products as specified in the BCBSM/BCN medical utilization management drug list.

BCBS Mississippi

Biofeedback: Biofeedback as a Treatment of Urinary Incontinence in Adults: This policy has been reviewed and updated with the following changes to coding:

• 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient
• 90913 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)

The CPT code below was deleted from the medical policy:

• 90911 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry

Read the complete update.

Percutaneous Tibial Nerve Stimulation: This policy has been reviewed and updated with the following changes to coding:

The codes below were added to the medical policy:

• 0587T - Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0588T - Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0589T - Electronic analysis with simple programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 1-3 parameters
• 0590T - Electronic analysis with complex programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 4 or more parameters

Read the complete update.

Gene Expression Profiling for Prostate Cancer: This policy has been reviewed and updated with the following changes to coding:

The investigational CPT code below was added to the medical policy:

• 81542 - Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score

Read the complete update.

Transurethral Water Vapor Thermal Therapy for Benign Prostatic Hyperplasia: BCBS Mississippi has published a new policy for transurethral water vapor thermal therapy for the treatment of BPH.

Transurethral water vapor thermal therapy is considered investigational as a treatment of benign prostatic hyperplasia. Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary.

Read the complete update.

BCBS North Dakota

Biofeedback: This policy has been reviewed and updated with the following changes to coding:

The codes below were added to the medical policy:

• 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient
• 90913 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)

The CPT code below was deleted from the medical policy:

• 90911 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including emg and/or manometry

BCBS South Carolina

Biofeedback as a Treatment of Urinary Incontinence in Adults: This policy has been reviewed and updated with the following changes to coding:

The following codes were added to the medical policy:

• 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient
• 90913 - Each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient

Read the complete update.

CarePlus

Master PA Criteria: The prostate cancer drug Erleada was reviewed with the following changes to criteria:

Covered Uses: All FDA-approved indications not otherwise excluded from Part D.

Exclusion Criteria: Members that have experienced disease progression while on Erleada (apalutamide). Concoitant use with an androgen receptor inhibitor or androgen synthesis inhibitor (e.g., enzulutamide, abiraterone, nilutamide, flutamide, bicalutamide) due to lack of evidence supporting efficacy and safety.

Required Medical Information: Prostate Cancer (non-metastatic castration resistant): The member has a diagnosis of non-metastatic castration resistant prostate cancer AND the member has a prostate-specific antigen doubling time (PSADT) of less than or equal to 10 months AND the member will use Erleada (apalutamide) in combination with androgen deprivation therapy (e.g. previous bilateral orchiectomy or GnRH analog). Prostate Cancer (metastatic castration-sensitive): The member has a diagnosis of metastatic castration-sensitive prostate cancer AND the member will use Erleada (apalutamide) in combination with androgen deprivation therapy (e.g. previous bilateral orchiectomy or GnRH analog).

Age Restrictions: None

Prescriber Restrictions: Licensed Practitioner

Coverage Duration: 6 months duration

Read the complete update.

CGS Administrators

Decipher Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease (MolDX) LCA A57796: CGS Administrators has published a new Local Coverage Article (LCA) to address billing and coding that complement the LCD for "MolDx: Decipher Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease L38077".

Read the complete update.

Next-Generation Sequencing for Solid Tumors (MolDX) LCA A57870: CGS Administrators has published a new Local Coverage Article (LCA) to address billing and coding that complement the LCD for "MolDx: Next Generation Sequencing for Solid Tumors L38067".

Read the complete update.

Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MolDX) LCA A56984: This LCA has been reviewed with the following changes to coding due to the annual coding update:

The code below was added to the group 1 section of the medical policy:

• 81542 – Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score

The code below was removed from the group 1 section of the medical policy:

• 81479 was removed from the first bullet and replaced with CPT code 81542 under article text.

Read the complete update.

eviCore Healthcare

Decipher Prostate Cancer Classifier: EviCore Healthcare has reviewed its Decipher Prostate Cancer Classifier medical policy and updated it with the following changes to coding:

Added the following CPT code:
81542 - Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score

Removed the following CPT code:
81479 - Unlisted molecular pathology procedure

Read the complete update.

Health Alliance Plan of Michigan

Lupron/Leuprolide Acetate:  This policy has been reviewed and updated with the following changes to criteria:

• Revised policy statement, changing subject from Lupron 3.75 mg to “Lupron 3.75 mg IM once monthly or 11.25 mg IM every 3 months”.
  Added recommended duration of therapy 3 months or less for treatment of anemia secondary to leiomyoma in members who are to have a surgical correction, and who have not responded to oral iron therapy alone.
  Removed a statement which indicated that, for provider offices that cannot buy and bill the medication, the member may receive the medication through Specialty Pharmacy, Pharmacy Advantage.

Read the full update.

Highmark Inc.

Zytiga and Yonsa: Highmark Inc. has reviewed its Zytiga and Yonsa pharmacy policies and updated them with the following changes to criteria and supporting information:

Zytiga

When a benefit, coverage of Zytiga may be approved when one of the following criteria are met:

• Zytiga is used in combination with prednisone and the following:
  • The member has a diagnosis of castration-resistant prostate cancer.
  • The member has a diagnosis of metastatic high-risk castration-sensitive prostate cancer.
• Documentation that generic abiraterone acetate is ineffective or not tolerated.

Quantity Limits

• When a benefit, additional quantities of Zytiga 500 mg, up to 4 tablets per day, may be approved when the following criterion is met:
  • The member is taking a strong CYP3A4 inducer.

Yonsa

When a benefit, coverage of Yonsa may be approved when all of the following criteria are met:

• Yonsa is to be used in combination with methylprednisolone.
• The member has been diagnosed with metastatic castration-resistant prostate cancer.
• Documentation that generic abiraterone acetate is ineffective or not tolerated.

Quantity Limits

When a benefit, additional quantities of Yonsa 125 mg, up to 8 tablets per day, may be approved when the following criterion is met:

• The member is taking a strong CYP3A4 inducer.

For Commercial and Healthcare Reform members enrolled in a Delaware plan, an exception to select criteria within this policy may be made based on Policy J-651 – Delaware—Cancer Chemotherapy Override Exception—Commercial and Healthcare Reform (An exception to select criteria within the respective policies may be made for members enrolled in a DE plan).

Read the complete update.

Humana

Urinary Incontinence Treatments: Humana has reviewed its Urinary Incontinence Treatments medical policy and updated it with the following changes to criteria, coverage limitations, coding, and supporting information:

Revised criteria for the following indications:

• Stress urinary incontinence (SUI) - is the involuntary loss of urine without a bladder contraction which occurs when the muscles and tissues around the bladder (eg, pelvic floor, sphincter) get weak or do not work. Urine may leak when there is pressure exerted on the bladder through actions like coughing or sneezing.
• Urge urinary incontinence (UUI) - is the involuntary loss of urine associated with a bladder contraction. It is a sudden, overwhelming urge to urinate due to involuntary contractions of the muscular wall of the bladder, which may cause an unintentional loss of urine. Frequent urination, including nocturia, can also occur. Other types of UI include, but may not be limited to, mixed incontinence which may present with symptoms of both stress and urge incontinence and overflow incontinence which occurs when the bladder does not empty completely causing leakage if the bladder becomes overly full.

 Updated coverage limitations:

Humana members may NOT be eligible under the Plan for urinary incontinence treatments for any indications other than those listed above including, but may not be limited to:

• Extracorporeal magnetic innervation (ExMI) (e.g, NeoControl Pelvic Floor Therapy System); OR
• Implanted percutaneous tibial nerve stimulation (PTNS) (eg, CAN-Stim System, RENOVA, StimRouter); OR
• Laser procedures (e.g, IncontiLase, FemTouch); OR
• Nonimplanted percutaneous tibial nerve stimulation (PTNS) (eg, NURO System, Urgent PC) for any indication not listed above OR if used longer than 12 months; OR
• Sacral nerve stimulation (eg, Axonics Sacral Neuromodulation System, InterStim, InterStim II) for any indication not listed above OR if the following contraindications are present:
  • Bilateral stimulation; OR
  • Bladder capacity less than 100 ml; OR
  • Bladder outlet obstruction present (eg, prostate hypertrophy, urethral stricture); OR
  • Individual not capable of operating the device; OR
  • Less than 16 years of age; OR
  • Pregnancy, unborn fetus and delivery; OR
  • Presence of progressive, systemic neurologic diseases64, 74; OR
• Stem cell transplantation; OR
• Transperineal implantation of permanent adjustable balloon continence device (e.g, ProACT system, ACT system); OR
• Transurethral radiofrequency ablation (eg, Renessa procedure); OR
• Urinary prosthesis (e.g, inFlow Intraurethral Valve Pump)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

 Humana members may NOT be eligible under the Plan for enuresis (bed wetting), alarms. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

 Humana members may NOT be eligible under the Plan for vaginal tactile imaging (or biomechanical transvaginal mapping). This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for UI devices (e.g, nonimplantable muscle stimulators utilized outside of a clinical setting [eg, Apex, Attain]) or supplies (eg, hygienic items, incontinence garments [eg, briefs, diapers, pads, penile wraps, underpads] and urethral inserts) for any indication. Although they may be prescribed by a health care practitioner, these UI devices and supplies are available without a prescription and may be obtained over-the-counter (OTC) and are generally contractually excluded. In the absence of a contractual exclusion for OTC items, these UI devices and supplies are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Added the following new CPT codes, effective 01/01/2020:

• 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient
• 90913 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)

Added the following new non-covered CPT codes, effective 01/01/2020:

• 0587T - Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0588T - Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0589T - Electronic analysis with simple programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 1-3 parameters
• 0590T - Electronic analysis with complex programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 4 or more parameters

Added the following HCPCS code:

• E1399 - Durable medical equipment, miscellaneous

Removed the following HCPCS code:

• A4337 - Incontinence supply, rectal insert, any type, each
  

Read the full update.

Kaiser Permanente

Benign Prostatic Hyperplasia Treatments: Kaiser Permanente has published a new policy for BPH Treatments.

Prostatic urethral lift may be considered medically necessary when ALL of the following criteria are met:

• age 50 or above
• prostate volume < 80 cc on ultrasound imaging
• no obstructive median lobe of the prostate identified on cystoscopy
• failure, contraindication or intolerance to at least six months of conventional medical therapy for BPH (e.g., at least one drug trial from one of the following categories: alpha blocker, PDE5 Inhibitor, finasteride/dutasteride)

Read the full update.

Minnesota Medicaid

Nubeqa PA Criteria: Minnesota Medicaid has published new PA criteria for the prostate cancer drug Nubeqa. Nubeqa may be approved if the following criteria are met:

·         Patient is ≥ 18 years old; AND

• Patient has a diagnosis of non-metastatic castration-resistant prostate cancer (nmCRPC); AND

• Patient has a prostate-specific antigen (PSA) doubling time of ≤ 10 months; AND

• Patient has a baseline PSA > 2 ng/mL; AND

• Patient will receive a gonadotropin-releasing hormone analog (GnRH) analog or has had a bilateral orchiectomy; AND

• Darolutamide will NOT be used in combination with other androgen receptor inhibitors (enzalutamide, apalutamide, etc.); AND

• Patient will avoid concomitant use with the following drugs or will be closely monitored as clinically appropriate:

• Combined P-gp and strong or moderate CYP3A4 inducer (rifampin, carbamazepine, St. John’s Wort, etc.,); OR

• Breast cancer resistance protein (BCRP) substrates (glyburide, statins, prazosin, etc.,)

• Initial approval is for 6 months

Read the complete update.

Nebraska Blue

Adjustable Balloon Continence Devices: Nebraska Blue has reviewed its Adjustable Balloon Continence Devices medical policy with the following change to coding:

Removed the following HCPCS code:
C9746 - Transperineal implantation of permanent adjustable balloon continence device, with cystourethroscopy, when performed and/or fluoroscopy, when performed

Read the complete update.

Providence Health Plan

Combined Prior Authorization List: Providence Health Plan has updated its Combined Prior Authorization List with several coding additions, revisions, and deletions. Relevant to urology, the following code was revised:

52287 - Cystourethroscopy, with injection(s) for chemodenervation of the bladder

Read the complete update.

QualChoice

Nubeqa: QualChoice has published a new pharmacy policy for the prostate cancer drug Nubeqa.

Nubeqa (darolutamide) is considered medically necessary for patients meeting the following criteria:

• Age 18 years or older AND
• Diagnosis of non-metastatic castration resistant prostate cancer (nmCRPC) AND
• Patient will use gonadotropin-releasing hormone (GnRH) analog concurrently (e.g. Lupron, Zoladex, Trelstar) or has had a bilateral orchiectomy Limits

As an oral specialty drug, limited to maximum 30 day supply per fill.

Read the complete update.

Total Healthcare

Specialty Drugs Requiring Prior Authorization: Total Healthcare has reviewed and updated its Specialty Drugs PA List with several additions. Relevant to urology, the prostate cancer drug Nubeqa was added to the list of specialty drugs requiring prior authorization.

Read the full update.

Tufts Health Plan

Prolia, Xgeva: Tufts Health Plan has reviewed its pharmacy policy for the drugs Prolia and Xgeva and updated it with the following changes to criteria:

Prolia

The plan may authorize coverage of Prolia (denosumab) when the following criteria are met:

Men with nonmetastatic prostate cancer

• Documentation the Member has a diagnosis of nonmetastatic prostate cancer AND
• Documentation the Member is at high risk of fracture defined as one of the following:
  • History of osteoporotic fracture
  • Multiple risk factors for fracture and a T score at the lumbar spine, total hip, or femoral neck of less than -1.0 as evidenced via bone density scan AND
• Documentation the Member is receiving androgen deprivation therapy AND
• Documentation of the following:
  • For Commercial Products, Tufts Health Direct, and Tufts Health Together
    • The Member has had an inadequate response to, or is unable to tolerate therapy with ≥1 bisphosphonate (e.g., alendronate, ibandronate, risedronate, zoledronic acid)
    • For Tufts Health RITogether
    • The Member has had an inadequate response to, or is unable to tolerate therapy with ≥2 bisphosphonates (e.g., alendronate, ibandronate, risedronate, zoledronic acid)

Xgeva

The plan may authorize coverage of Xgeva (denosumab) when the following criteria are met:

• Documentation the Member has bone metastases from multiple myeloma or solid tumors AND is receiving Xgeva for prevention of skeletal-related events OR

• Documentation the Member is being treated for unresectable giant cell tumor of bone or surgical resection of GCTB is likely to result in severe morbidity OR

• Documentation the Member has a documented diagnosis of hypercalcemia of malignancy AND has had an inadequate response to, or is unable to tolerate therapy with at least one bisphosphonate (e.g., alendronate, ibandronate, risedronate, zoledronic acid)

Read the full update.