Download Actonel , risedronate- Containing Medications (Actonel, Actonel with

Medication Policies
The Regence Group and its affiliated Plans use medication policies for coverage
decisions within the member’s written benefits. Below are summaries of recent
changes to The Regence Group’s medication policies. The detailed policies and
complete Medication Policy Manual are available online at
http://www.blue.regence.com/policy/medication/contents.html. We have
included the policy number for your convenience.
NEW POLICIES (PUBLISHED WITHIN THE LAST 6 MONTHS)
Policy Name and
Number
Summary of Policy
Approval
Date
New policy allowing coverage of Actonel-containing
medications when a generic oral bisphosphonate,
such as alendronate, was not tolerated or is
contraindicated
7/18/2008
Policy effective December 1, 2008. New policy
allowing coverage of IV Boniva when an oral
bisphosphonate, such as alendronate, was not
tolerated or is contraindicated.
7/18/2008
New policy allowing coverage of oral Boniva when a
generic oral bisphosphonate, such as alendronate, and
oral Actonel® has been ineffective or is
contraindicated.
7/18/2008
Policy effective December 1, 2008. New policy
allowing coverage of Reclast when an oral
bisphosphonate, such as alendronate, was not
tolerated or is contraindicated.
7/18/2008
New policy allowing coverage of Arcalyst for
cryopyrin-associated periodic syndromes (CAPS)
when there is laboratory evidence of mutation in the
CIAS1 gene, and there is documentation that the
patient is experiencing classic CAPS symptoms
resulting in significant functional impairment.
7/18/2008
(Click on policy name
for link to policy)
Actonel®, risedronateContaining Medications
(Actonel, Actonel with
Calcium)
Dru155
Boniva®, ibandronate
injection
Dru156
Boniva®, ibandronate
oral
Dru157
Reclast®, zoledronic
acid
Dru158
Arcalyst®, rilonacept
Dru159
© 2008 The Regence Group. All rights reserved.
Page 1 of 5
NEW POLICIES (PUBLISHED WITHIN THE LAST 6 MONTHS) - CONTINUED
Policy Name and
Number
(Click on policy name
for link to policy)
Cimzia®, certolizumab
pegol
Dru160
Relistor®,
methylnaltrexone
Dru161
Nplate®, romiplostim
Dru162
Approval
Date
Summary of Policy
New policy allowing coverage of Cimzia for the
treatment of Crohn’s disease following prior
unsuccessful treatment with systemic corticosteroids
or an oral immunomodulatory medication and either
Humira® or Remicade®.
7/18/2008
New policy allowing coverage of Relistor for opioidinduced constipation in terminally ill patients when
treatment with a standard bowel regimen has been
ineffective.
9/12/2008
New policy allowing coverage of Nplate for
idiopathic thrombocytopenia purpura (ITP) when
other treatments have been inadequate.
11/14/2008
© 2008 The Regence Group. All rights reserved.
Page 2 of 5
Policy Updates as of November 14, 2008
Policy Name
Summary of Changes
(Click on policy name
for link to policy)
Policy No.
Actiq®, fentanyl citrate
oral transmucosal
lozenges
Policy update – No Criteria Changes
Amerge®, naratriptan
Policy update – No Criteria Changes
Dru052
Amevive®, alefacept
Policy update – No Criteria Changes
Dru088
Axert®, almotriptan
Policy update – No Criteria Changes
Dru053
Celebrex®, celecoxib
Policy update – No Criteria Changes
Dru041
No Criteria Changes
Dru002
Policy archived
Dru089
Cimzia®, certolizumab
pegol
Policy update – No Criteria Changes
Dru160
Effexor XR®,
venlafaxine extendedrelease capsules
Policy update – No Criteria Changes
Dru146
Emend®, aprepitant
No Criteria Changes
Dru091
Enbrel®, etanercept
No Criteria Changes
Dru035
Fentora®, fentanyl
buccal tablet
Policy update – No Criteria Changes
Dru141
Frova®, frovatriptan
No Criteria Changes
Dru054
Gleevec®, imatinib
mesylate
No Criteria Changes
Dru043
Humira®, adalimumab
No Criteria Changes
Dru081
Imitrex®, sumatriptan
No Criteria Changes
Dru055
Kineret®, anakinra
No Criteria Changes
Dru049
Cerezyme®,
imiglucerase
Chelation Therapy
Dru073
Policy updated to state that quantities exceeding 96
lozenges per month are considered not medically
necessary.
© 2008 The Regence Group. All rights reserved.
Page 3 of 5
Policy Updates as of November 14, 2008 - CONTINUED
Policy Name
Summary of Changes
(Click on policy name
for link to policy)
Policy No.
Kytril®, granisetron
No Criteria Changes
Dru068
Maxalt®/Maxalt MLT®,
rizatriptan
No Criteria Changes
Dru056
Orencia®, abatacept
No Criteria Changes
Dru129
Opana ER®,
oxymorphone extendedrelease
Policy update – criteria changes
Dru142
Opioids for Chronic
Non-Cancer Pain
Policy update – criteria changes
OxyContin®,
oxycodone, Controlled
Release
Policy update – criteria changes
Raptiva®, efalizumab
No Criteria Changes
Dru104
Relpax®, eletriptan
No Criteria Changes
Dru092
Policy update – No Criteria Changes
Dru036
Remicade®, infliximab
Reauthorization criteria simplified by removing
requirement that patient be evaluated by consulting
physician specializing in area thought to be the
source of the patient’s non-cancer pain.
Dru084
Reauthorization criteria simplified by removing
requirement that patient be evaluated by consulting
physician specializing in area thought to be the
source of the patient’s non-cancer pain.
Dru042
Reauthorization criteria simplified by removing
requirement that patient be evaluated by consulting
physician specializing in area thought to be the
source of the patient’s non-cancer pain.
Position statement updated to include “Efficacy in
Rheumatic Conditions,” Efficacy in Crohn’s
Disease” and “Efficacy in Plaque Psoriasis” tables.
Sprycel®, dasatinib
No Criteria Changes
© 2008 The Regence Group. All rights reserved.
Dru137
Page 4 of 5
Policy Updates as of November 14, 2008 - CONTINUED
Policy Name
Summary of Changes
(Click on policy name
for link to policy)
Stadol NS®, butorphanol Policy archived
tartrate nasal spray
Policy No.
Dru063
Tasigna®, nilotinib
No Criteria Changes
Dru151
Zavesca®, miglustat
No Criteria Changes
Dru109
Zofran®, ondansetron
No Criteria Changes
Dru046
Zomig®/Zomig ZMT®,
zolmitriptan
No Criteria Changes
Dru057
© 2008 The Regence Group. All rights reserved.
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